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In this report, the Norwegian Board of Health Supervision presents examples and describes the experience we have gained from investigation of serious adverse events that have been reported to us during the period 1 June 2010 to 31 December 2013. We describe reports from various hospital departments, how we have dealt with these reports, and the assessments we have made. We also present statistics giving an overview of the number of reports from the different health trusts and hospital departments.

Specialized health services have a duty to report serious adverse events to the Norwegian Board of Health Supervision. This reporting system was established in the spring of 2010 after several serious adverse events in hospitals received a great deal of public attention.

The aim of the reporting system is that the supervision authorities shall be able to obtain an informed overview of serious adverse events in which a patient has died or suffered serious injury when receiving treatment in a hospital. The Norwegian Board of Health Supervision works closely with the health care personnel and hospitals involved to ensure that we have all the relevant information about the event and about how the organization is managed and driven. Our investigation also includes talking to the patients and relatives, and listening to their account and experiences of the event. We investigate and analyse causality, assess whether treatment was provided in accordance with sound professional standards, and stimulate the services to learn from the experience they have gained. In this way, the supervision authorities contribute to reducing the risk that the same event can happen again, and we support the work of hospitals to improve patient safety.

Professionals in the hospitals are an important target group for the report. Our hope is that the report will stimulate reflection and debate about patient safety, the risk of errors and deficiencies occurring, and the possibilities for improving patient care.

Could this have happened here? Examples and experience gained from investigation of serious adverse events 2010–2013 Serious Adverse Events in Hospitals

Report from the Norwegian Board of Health Supervision 3/2014 (pdf) Full Text in English