Summary in English

Commissioned by the Ministry of Health and Care Services (HOD), the Norwegian Board of Health Supervision has reviewed and analyzed notifications of serious adverse events in the health service. In this report, we present and summarize key figures from the notification scheme up until the new reporting scheme for the health and care services entered into force on 1 July 2026.

We also present two topics in which we highlight our specific supervisory experience and key lessons learned relating to serious adverse events that have occurred:

1. Medication management in the municipal health service
2. Follow-up of women showing signs of severe postnatal depression

Finally, we discuss the Norwegian Board of Health Supervision’s project: “Knowledge-based supervision of the health and care services”. The Norwegian Board of Health Supervision has begun work to develop more knowledge about how the supervisory authority can contribute to a greater extent to learning and improvement in the health and care services. In this connection, we held a seminar to which we invited participants from the health and care services, patient and next-of-kin representatives, representatives of the supervisory authority, and researchers from five different countries. The aim was to bring together a range of participants with important experience and expertise who could shed light on and discuss how serious adverse events are followed up today, and how supervisory authorities can contribute to better follow-up of serious adverse events and more learning and improvement.

This report is the third in a series of reports on serious adverse events in the health and care services published by the Norwegian Board of Health Supervision.