Learning from mistakes and complaints
Summary of Report of the Norwegian Board of Health Supervision 7/2009
This book is a follow-up of the pamphlet “Colleague-based learning from cases of complaint”
(“Kollegabasert læring av klagesaker”) from 1995, published by the Norwegian Medical Association in cooperation with the Norwegian Board of Health Supervision. Later, on several occasions, both the Director General of the Norwegian Board of Health Supervision and the President of the Norwegian Medical Association have pointed out the need for learning from errors that are made in the health services.
Therefore, we have produced a collection of examples. We present a broad range of serious and less serious events and case histories, based on complaints that have been dealt with by the supervision authorities and the Norwegian System of Compensation for Injuries to Patients. The cases are from general practice and the emergency services, and are, of course, made anonymous.
The theoretical part presents information about the following: errors in general medical practice, dealing with cases of complaint, doctors’ reactions to making errors, and how complaints can best be dealt with. Pedagogical challenges and possibilities are described and discussed. During the last few years, focus has been directed towards errors made by doctors from other countries. This issue is discussed in the book, including a review of how general practice can be organised in order to prevent errors. The authors are all authoritative persons in the fields of teaching, research and supervision of services.
We hope that the book will provide the basis for discussion among medical students, junior doctors, and general practitioners undergoing specialist training or further education. It has been shown that the potential for learning is greatest in such processes with colleagues.
Learning from mistakes and complaints (pdf in Norwegian) Report from the Norwegian Board of Health Supervision 7/2009