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Complex care pathways, complicated, serious illnesses and injuries, lead to a higher risk of complications and the occurrence of adverse events.

In 2015, the Investigation Unit for Serious Adverse Events received and dealt with 501 reports of serious adverse events in hospitals. The number of reports has steady increased since the system for reporting was established in 2010.

This report is an annual publication of the Norwegian Board of Health Supervision, and is part of the task of the Investigation Unit for Serious Adverse Events to give special attention to learning from the cases from the previous year. It contains several articles that illuminate different aspects of our activities and the experience we have gained from the reporting system. The report also presents facts and figures that provide an overview of reports according to health trust, type of event and how we have followed up the reports. We have also invited external authors to contribute, to give a different perspective from ours.