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Quality & safety

Of course our patients count on qualitative and safe care. However, care is human work. We learn from what went well, we improve prospectively, and we learn from care that did not go the way we had intended. In our safety management system, we keep an eye on risks, learn what could be better, and based on this, take action to make improvements. Despite this, there are some patients who have an unpleasant experience . We do our best to discuss it, learn from it, and get rid of any causes of displeasure.

If an incident or major incident occurs, we investigate thoroughly what factors contributed to the fact that something in the care process did not go according to plan. We also look at how we can prevent it from happening again in the future, and how we can continue to improve the quality of our care and the safety of our patients. We have discussions on complications in all healthcare departments and brainstorming and listen-and-learn sessions take place several times a year. The Adrienne Cullen lecture also plays an important part in making it possible to talk about and learn from incidents. The third Adrienne Cullen lecture took place in 2021. Another important step that we took in 2021 was the further development of our quality management system, whereby the traceability of protocols has been improved and cross-links made visible.

Diagnosis follow-up

To increase patients’ safety even further in 2021, we continued further with the improvement of follow-up of diagnosis results. Every year at UMC Utrecht we perform about 200,000 imaging diagnosis (including MRI scans, X-rays and CT scans) and around 5 million laboratory analyses (including blood tests). In addition, pathological, genetic and medical microbiological diagnoses also take place. It is a complex process with various stages in which things sometimes go wrong. Sometimes the result of the requested diagnosis does not reach the caregiver, or not in time. Missed diagnoses can have severe consequences for a patient.

In 2021 we conducted various improvements to ensure that diagnosis results reach healthcare professionals and patients properly, so that if necessary the right treatment can be started on time. We have thus explained the policy and work processes and made the Electronic Patient Record (EPR) more user-friendly for healthcare professionals. Together with the divisions, agreements were made to further reduce the risks of missed diagnoses.

Discharge communication improved

​​​​​​​​​​​​​​​​​​​​​​In 2021 we considerably improved our discharge communication. For the sake of care continuity, it is important for a patient’s general practitioner to be updated after a clinical hospitalization. For this, it is important to transfer information efficiently and fast. Our aim is to send a report to the general practitioner within 24 hours after discharge, describing what the diagnosis was, what treatment(s) the patient underwent, which medication the patient has received at the hospital and must use at home, and what the further arrangements are. In certain cases there will also be a comprehensive discharge letter. Our ambition is to send a discharge letter to the general practitioner/referrer within 24 hours in 90% of all cases when the patient goes home or is transferred to another institution, In January 2021 we sent less than 30% of all discharge letters on time. In December 2021, the figure went up to over 53%.

Incidents, major incidents, complaints

Day by day, our professionals work with passion to provide patients with the best care. Unfortunately things do not always go as planned, and an incident or major incident may occur. A patient may also have an unpleasant experience and submit a complaint.

In all cases, our policy is to help the patient concerned and/or their relatives as well as possible and to learn actively from an incident, major incident or complaint. In this way we want to avoid a similar situation in the future, and continue to improve the quality of our care and the safety of our patients.

Figure 1: Number of patient-care incidents reported (MIP)

The number of reported incidents went down compared to previous years. We suspect that the drop in regular care during the COVID-19 pandemic played a role here.

Figure 2: Number of reports of (possible) major incidents


Interne meldingen

Mogelijke calamiteiten

Uiteindelijke calamiteiten

























  • 1 In the annual report on 2020, we reported 20 possible severe incidents. Since it was decided in 2021 also to include severe incidents that were reported by the Princess Máxima Center in the figures of UMC Utrecht whenever UMC Utrecht was involved, the final number of reports for 2020 is 21 instead of 20. UMC Utrecht has of course informed IGJ of this.

The number of (possible) major incidents in 2021 was about the same as in 2020, and relatively lower than in previous years. We suspect that the drop in regular care during the COVID-19 pandemic played a role here. The number of reported (possible) major incidents is approximately the same as in other UMCs.

Figure 3: Number of complaints at Complaints Mediation

Patient Support and Peer Support

A major incident, incident or other upsetting care-related event has a great impact on the patient in question and their families, as well as on healthcare professionals. We therefore offer patients and their families support from the Quality & Patient Safety Directorate via Patient Support, among others. Colleagues support each other through a formal collegial structure (Peer Supporter network). Besides that, colleagues also support each other informally.

In 2021, we offered Patient Support 21 times (20 times in 2020). The Peer Support team in 2021, just as in 2020, provided Peer Support 50 times to colleagues. This was done both in one-to-one and in group sessions following traumatic events in the hospital. In 2021, 10 new Peer Supporters were also trained. In total, there were 86 colleagues in 2021 who could provide Peer Support (83 in 2020).

Read more about how we deal with incidents , major incidents and complaints at UMC Utrecht.