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This report shows that the number of reports of injuries to patients in 2001 and 2002 was less than in previous years. The reduction is believed to be mainly associated with the fact that the duty to report now encompasses events that led to, or could have led to, substantial injury to patients. Previously, near-misses (sentinel events) and events that occurred, but that did not result in injury to patients, were also reported.

Based on the experience gained from supervision of health services, the Norwegian Board of Health finds that there are large differences with regard to how far Norwegian health institutions have come in their work with systematic quality improvement, and that the institutions appear to use reports of adverse events only to a limited degree in this work. However, the reports indicate certain problem areas, and even though the picture is not complete, there is no reason to reduce the requirement for health services to pay more attention to their work with quality improvement.

The Norwegian Board of Health believes that many adverse events that could have led to substantial injury to patients are not reported. We are particularly concerned that this under-reporting may reflect a lack of systematic work with quality improvement, specifically in relation to the way in which health trusts deal with adverse events.