Marjon Borgert

201 Summary and future perspectives FUTURE PERSPECTIVE A hospital is a highly complex system. This complexity is due to the many interactions between humans (patients, family, health care professionals), the organization (teams, wards, hospital) and the nancial and political environment. 24 Dynamic systems such as ICUs are particularly complex, given the multitude of technologies, treatments, medications, severity of the illnesses of patients, and the fact that professionals work in multidisciplinary teams. Errors are very likely to occur in dynamic and complex systems. 18,25,26 In hospitals patient safety is an important issue that is also complex. Patient safety is broad-based, and operates at various levels of the system. It applies to various patient categories that employ multiple techniques and interventions, and can be in uenced by cultural, technical, clinical, psychological, and nancial aspects. 27 We conducted the studies included in this thesis within these complex contexts. One of the most challenging aspects of increasing patient safety in a hospital setting is the successful implementation of new evidence-based practices (Chapters 2 and 7). For each new implementation activity, there are a large number of factors that hamper implementation. Cabana et al. conducted a systematic review in which they identi ed barriers to physicians’ compliance with clinical guidelines. 28 These were barriers related to professionals’knowledge and attitudes as well as to external barriers such as patient-, guideline-, or environment-related factors. Successful implementation depends on considering these various barriers and searching for adequate implementation strategies to overcome them. 2,29,30 To achieve e ective implementation, a systematic approach and a well-designed implementation plan are imperative. The plan should include an analysis of the target group, the setting, and the existing barriers. 29 This information is necessary to tailor the implementation strategy to a speci c situation. Although audit and feedback (A&F) is a widely used implementation strategy for improving patient safety and quality of care, it appears to be only moderately e ective. 31 A&F is more likely to be successful when the source is a senior colleague or supervisor, when it is provided in both written and verbal formats, when the goals are measurable, or when it is provided in a timely fashion (i.e. at least once a month). 31 However, given the heterogeneity in outcome measures and methodology in the available studies, no strong conclusions can be drawn about A&F. 31 A wide variety of implementation strategies can be used, including reminders, A&F, and educational activities. These implementation strategies show varying e ects (Chapter 6), 32 and the most e ective strategy or combination of strategies for successful implementation remains elusive. 31 According to current thinking on this subject, to increase the chances of success, a tailored and often multifaceted approach is required