Marjon Borgert

203 Summary and future perspectives Risk management in hospitals is crucial to improving quality and increasing patient safety. 35 Care processes should be systematically monitored and analysed to identify potential risks.This provides valuable information about the variability that occurswithin care processes, and the results can then be used to nd opportunities for managing and reducing risks. 18 Care bundles are frequently used as tools to continuously monitor care processes. 14,17 They monitor the performance of professionals over time for a single process, which can be helpful in tracking progress towards outcomes and in making adjustments to performance if necessary (Chapter 7). They can be used to monitor prede ned outcome measures (i.e. quality indicators). 14,46 The quality indicator re ects a change that result from the implementation of the intervention. Thus, continuously monitoring the e ect the care bundle has on the prede ned quality indicator detects changesinaprofessional’sperformance(Chapter8).Theuseofqualityindicatorstogether with quality improvement interventions has proven to be e ective in improving quality of care. 47 However, general safety in hospitals cannot be improved by just one indicator for a single process. Multiple indicators should be used in combination with other approaches for monitoring safety on both hospital wards and across the organization, such as safety walks, monitoring safety at handovers, incident reporting, complaints procedure, complication registries and clinical audits. 40 Because health care practice and scienti c evidence changes over time, it is important to periodically evaluate and revise the set of quality indicators used. 47,48 One realistic aspect of monitoring indicators that needs to be addressed is that it implies an administrative burden for health care providers. Even though automated electronic data extraction can help to reduce the registration workload, 47 the decision to monitor indicators should be worth the e ort. Improving patient safety also involves being fully committed to the quality and safety of the entire organization. The concept of high reliability is often mentioned as facilitating risk management in hospitals and changing hospital systems and processes to achieve high quality of care. It is designed for those organizations that deal with dynamic, variable and unexpected circumstances, and has been adapted from industries outside of health care such as commercial aviation and nuclear power. 49 In organizations in these industries, humans work under hazardous and complex conditions, and safety has an extremely high priority, which results in exceptionally high levels of reliability. These high reliability organizations (HROs) are constantly searching for methods to reduce errors and harm, and are urged to cope with errors and quickly recover when things do go wrong. 49,50 Even though hospitals di er from the aviation and nuclear power industries, they can learn from how they think. 49,51 High reliability is a way of thinking about quality and safety, and a concept that helps hospitals achieve their quality and safety goals. Striving to become an HRO can be achieved by creating a safety culture and by optimizing processes that are e ective at reducing system errors, and can e ectively