Intended for healthcare professionals


Why patient safety is such a tough nut to crack

BMJ 2011; 342 doi: (Published 21 June 2011) Cite this as: BMJ 2011;342:d3447
  1. Ian P Leistikow, coordinator of patient safety center1,
  2. Cor J Kalkman, professor in anesthesiology; head of patient safety center1,
  3. Hans de Bruijn, professor of public administration and management2
  1. 1Patient Safety Center, University Medical Center Utrecht, Utrecht, Netherlands
  2. 2Policy, Organisation, Law and Gaming Group, Faculty of Technology, Policy and Management, Delft University of Technology, Delft, Netherlands
  1. Correspondence to: Ian Leistikow, Dutch Healthcare Inspectorate, PO Box 90137, 5200 MA Den Bosch, Netherlands; ianleistikow{at}
  • Accepted 16 May 2011

It’s now more than a decade since the US Institute of Medicine’s landmark 1999 report To Err Is Human put patient safety prominently on the international agenda. Despite countless initiatives, publications, and conferences on the topic, improvement has been disappointingly slow. Ian Leistikow and colleagues define the four challenges that make patient safety such a tough nut to crack, and propose a way out of the impasse

Patient safety has become a major concern in healthcare worldwide. Of patients admitted to hospitals, 3.7% to 17.7% are inadvertently harmed by the way their healthcare is delivered.1 2 Preventable adverse events lead to a larger annual loss of lives than traffic accidents, AIDS, or breast cancer.3 There is, however, a discrepancy between the gravity of the problem and the frailty of the solutions implemented to date.4 5 6 7 On the one hand there is incrementally increased attention paid to patient safety issues and pressure placed on healthcare professionals, organisations, and regulators to curtail the extent of unintended harm to patients. On the other hand, the pace at which solutions are applied is frustratingly slow and methodologically sound studies looking at the impact of implemented safety solutions have often found results that were ambiguous at best.8

The four challenges of patient safety

The four key challenges in implementing patient safety interventions, based on the literature, conferences, and the authors’ experiences in setting up a hospital-wide patient safety programme in a university medical centre, are: visibility, ambiguity, complexity, and autonomy.


Safety issues in healthcare are often not clearly visible. There is often no discernible distinction between a patient who has died because of a preventable adverse event, and any other deceased patient.

Further, even if a problem is recognised at the level of the individual patient, its magnitude can remain hidden from the healthcare professionals …

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