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This year's report deals specifically with our experience with the work of the health trusts with risk assessment before and after a serious adverse event, in cases we have followed up with on-site supervision. We describe examples from different areas with a focus on preventive or damage-reducing barriers. Preventive barriers are measures that reduce the risk of an adverse event occurring. Damage-reducing barriers are measures that reduce the seriousness of an event.

Organizations that provide health services have a duty to identify service provision where there is a high risk, and to initiate risk-reducing measures when necessary. If an adverse event occurs, they shall establish routines for damage-reducing measures. They also have a duty to learn from the adverse event, and, if necessary, to initiate further measures to prevent the same adverse event happening again.

When the supervision authorities carry out supervision to assess whether health service provision meets the statutory requirements, we also assess whether the organizations have identified special areas of risk, and whether they have learned from adverse events that have occurred.

Learning from adverse events requires detailed assessment of the event. Patients and relatives are an important source of information. Information obtained from patients, relatives and health personnel as soon as possible after the event gives the most possible complete picture of what has happened. It is then possible to identify the reasons why the event could happen, and to initiate measures to prevent similar events happening again.

The individual organizations have responsibility for providing sound treatment and for working continually to improve the services they provide. The supervision authorities can make an important contribution to improving patient safety. However, the key to effective reduction of risk lies with the individual organizations, with their attention to risk-reduction, and their commitment to this work.

Health professionals who work in the health trusts are an important target group for this report. We hope that the report leads to reflection and debate about patient safety, risk management and work with quality improvement in health organizations.