Serious Adverse Events in Hospitals – Status and Experience from the Investigation Unit for Serious Adverse Events 2014

Behind every serious adverse event in a hospital are the health trust and the health personnel, who all wish to do their job to the best of their ability. But first and fore­most, this is about the patients, who often are very ill, and who need medical treat­ment. Complex care pathways and serious illnesses and injuries involve a risk that complications can occur, and that things can go wrong for some patients.

In 2014, the Norwegian Board of Health Supervision received 414 reports from hospitals about serious adverse events. This report is based on examples of reported incidents, on the experience of the Investigation Unit for Serious Adverse Events (the Unit), on the work carried out in hospitals to follow up events, and on the report­ing system as laid down in Section 3-3a of the Specialized Health Services Act. We have also invited some relatives, some health trusts, and some of the Offices of the County Governors to share their experiences and to reflect over some of the chal­lenges they have encountered. The report also presents some facts and statistics, pro­viding an overview of the number of reports from the various health trusts, the type of incidents reported, and how the Unit has followed up the reports.

The aim of the report is to stimulate reflection and debate in the hospitals about chal­lenges related to patient safety and quality improvement. As a result of the dialogue between the Unit and the health trusts, health personnel, patients and relatives, the re­porting system is continuously being developed and changed.

According to health legislation in Norway, those who run health services are respon­sible for patient safety and for the quality of the treatment provided to patients. This means that leaders are expected to have a system for following up reports of serious adverse events and other reports about mistakes and inadequacies. Leaders who work actively and with clear aims to create a culture of transparency and safe reporting practice when things go wrong in their hospital, play an important role in improving patient safety.

Adequate professional supervision, including follow-up of reports of serious adverse events, helps to support the work done in hospitals to improve patient safety, and also helps to ensure that health services are managed in such a way that patients receive adequate services at all times.