Meny
Summary in English
On behalf of the Ministry of Health and Care Services (HOD), the Norwegian Board of Health Supervision has reviewed and analysed reports of serious adverse events in the health service. This report presents key figures from the reporting system for the last six months and describes what measures that, according to research and supervision, can ensure learning from patient safety incidents across health and care services and prevent new incidents.
We furthermore elaborate on three risk areas where we see potential for learning from serious adverse events: the introduction of welfare technology in the municipalities, exchange and follow up of information in the medical emergency response service, and the diagnosis and treatment of severe depression. The aim of the report is to highlight areas of increased risk and the need to ensure cross-sector learning.
The report Patient harm – continued opportunities for learning and improvement, which we submitted to the Ministry of Health and Care Services on 1 March 2025, described various barriers that can make it difficult to translate experience into learning and improvement in the healthcare service. These barriers are related to fundamental risk areas and the complexity of the healthcare service, as well as challenges in learning across services.
The health and care service is a complex system with countless different interactions, both human and technological. When serious adverse events occur, it is often due to failures in these complex interactions. In order to learn, the incident must be understood in light of this complexity, and not as an isolated incident where one or more health professionals did something wrong.
The approach to investigating a serious patient safety incident affects the potential for learning and improvement. In this report, we describe the types of measures that, according to research, can contribute to changing practice, and the measures we often see organisations implementing. Simple measures that often focus on individuals changing their behaviour, have shown to have only a short-term effect, while complex measures that combine different tools and target structures, can have a more long-term effect and lead to actual change.
Recent research shows that health providers often find themselves taking a systemic perspective when reviewing serious adverse events. In almost half of the incidents, however, health providers target factors such as the actions, behaviour and knowledge of healthcare personnel rather than the system. This perspective often results in measures aimed at individual healthcare personnel, which have limited effect on learning and improvement.
Analysing an incident when you know the consequences, can lead to hindsight bias and an oversimplification of the causal chain. A complex understanding of causes, as opposed to a linear understanding, can capture the complex interaction between people and the system components.
The report's three feature articles
- Welfare technology in municipalities: The report points out that the implementation of welfare technology requires thorough risk assessments, good training, clear responsibilities and continuous evaluation.
- Communication and flow of information in the medical emergency response service: The main findings show that failures in information gathering, lack of recognition of serious symptoms and poorly structured communication between collaborating health personnel increase the risk of serious incidents.
- Suicide in severe depression: Patients with severe depression are overrepresented among patients who commit suicide while undergoing treatment in the health service. The patient's symptoms and signs can be challenging to detect and are often interpreted as more common and less serious conditions.
To learn from serious adverse events, organisations must move from individual, simple measures to comprehensive, systematic and lasting improvement measures that take into account the complexity of the healthcare service. In this way, learning can be translated into better practice and increased patient safety.