Annual Report 2005 for MedEvent (Meldesentralen – the Reporting System for Adverse Events in Specialized Health Services)
Summary of Report of the Norwegian Board of Health Supervision 1/2007
For 2005, 1 902 adverse events were registered (registered per 1 September 2006). Such events involve a duty to report to the Norwegian Board of Health Supervision in the counties, in accordance with the Specialized Health Services Act, section 3-3.
The number of reports of injuries to patients increased by 59 per cent during the period 2001 to 2004. There was a decrease of about 6 per cent in the number of reports from 2004 to 2005.
About one third of the reports (34 per cent) were reports of serious injury to patients, and over half (52 per cent) were reports of events that could have led to serious injury.
191 reports of unnatural death were registered. In 51 per cent of these reports, the death occurred when providing health care, and in 26 per cent, the death occurred as a result of self-inflicted injury.
Seven per cent of the reports were related to childbirth. In 79 per cent of these, the event was related to the mother, and in 21 per cent it was related to the baby.
One per cent of the reports were related to blood, blood products and blood transfusions. None of these reports were of unnatural death.
Fourteen per cent of the reports were related to events that had occurred in mental health services, and 63 per cent of these related to self-inflicted injuries, such as self-inflicted wounds, suicide and attempted suicide.
Many adverse events that should be reported, are still not reported. Openness about adverse events, injuries and near misses, and systematic use of information about such events, form the basis for satisfactory work with improving safety. This presupposes a positive attitude to reporting. It is also important for leadership to focus on systematic safety-improvement work.