Marjon Borgert

12 Chapter 1 ‘the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from healthcare itself. It should address events that span the continuum of “errors” and “deviations” to accidents’. 11 Learning from incidents To improve patient safety, it is important to understand the causes of potentially preventable adverse events. Analysing adverse events and searching for interventions to prevent them is one way to gain insight into these causes. Progress has beenmade on the quality of patient safety research itself as well as on incident analyses. In the earlier days of patient safety research, incidents were viewed as a substandard performance by individual professionals, and inattentiveness, distractions, and low motivation were some of the reasons given for their occurrence. 10 Nowadays, though, incidents are seen more as problems resulting from organizational or system-wide factors. 12,13 Health care professionals are in uenced by the work they are doing, the team they are part of, their working environment, and the organization they work for, which are known as system factors. 14 The actions of professionals are in uenced by processes within the broader organization or within their local working environment. A slogan coined by Paul Batalden from the Institute for Healthcare Improvement (IHI) underlines this principle: ‘Every system is perfectly designed to get the results it gets’. 15 Quality chasm Many patients come to harmbecause professionals do not consistently follow evidence- based recommendations or guidelines. 11 Guidelines aim to reduce variability in clinical care and to increase adherence to evidence-based interventions. 10 However, studies suggest that patients receive only about 50% of the recommended care, or undergo unnecessary or harmful treatments or investigations. 16,17 This problem actually starts with the slow uptake and dissemination of research ndings from biomedical science in hospitals. Often, multiple studies have to be conducted before new ndings become o cial recommendations for clinical practices. 18 One important reason for this is the external validity, generalization and applicability of new resarch ndings. 19 Often, studies do not provide su cient contextual information, which makes it hard to make judgements about the applicability of study results. Subsequent studies have shown that implementation of these recommendations lags even further behind. This means there is a large gap between the time new research ndings become available and when they are actually incorporated into daily care practices. As a consequence, the clinical care many patients receive during this gap is not in line with the latest research