1. Summary in English

Until 1 July 2019, the duty to report serious incidents to the Norwegian Board of Health Supervision only applied to the specialist health service. After this date, the municipal health and care services were imposed a similar duty to report and patients, service users and next of kin were also given the right to report serious incidents. During the first four years after the reporting scheme was extended, the Norwegian Board of Health Supervision received reports of 873 incidents involving municipal health and care services that met the criteria set out in the reporting scheme. The reports were mainly received from managers in the municipal health and care services.

The incidents that were reported most frequently concerned medical examinations/diagnostics (17 per cent), falls (13 per cent) and use of medications (9 per cent). Most incidents occurred in nursing homes or other institutions (310 incidents) and in connection with home-based health and care services (180 incidents), accident and emergency departments / EMS communications centres (152 incidents) and general practitioner services (100 incidents). In 529 of the cases (61 per cent), the patient died.

We have carried out 16 supervisory audits following reports concerning municipal health and care services. The audits identified several risks and areas for improvement, including the following:

• Collaboration is particularly important for patients/users who are followed up at several different service locations within the municipality, in the specialist health service and in emergency situations. This requires improvements with regard to clear lines of responsibility, collaboration and expertise within the various services. We saw that there were issues concerning collaboration agreements between employees, departments and hospitals and between the different levels of the health and care services. Structures must be in place that facilitate proper communication and information flows among employees, between different administrative levels and with relatives.
• We found that the accident and emergency departments and municipal acute inpatient units had inadequate systems for ensuring medical supervision during busy periods and for detecting changes in the patient's condition after admission in order for any acute deterioration to be adequately managed.
• Lack of an overview of risk areas in connection with reorganisation/operational changes.
• Lack of risk assessments before the introduction of technological solutions, for example in the use of welfare technology and digital solutions for collaboration between employees and between different units/organisations.
• Learning from previous errors: several supervisory audit cases reported that previously reported nonconformities, acknowledged risk factors and audits have not been used to any great extent in subsequent improvement work. Nonconformity cases and supervisory audit reports had not been communicated to employees to any great extent.
• Procedures for e.g. the use of medical devices. We saw that procedures were either not in place, were unknown or had not been applied correctly. We also found organisations that lacked systems to ensure that employees were familiar with and able to use equipment and that any training received was not systematic and documented.
• With regard to medication management, we found problems related to the fact that support systems for medication management existed at the unit but were not applied; there was a lack of internal control concerning medication management; or no assessments had been made concerning the risk of drug interactions.

The purpose of the reporting scheme is to identify incidents and service delivery failures more quickly, so that these can be corrected and patient safety can be improved. In our supervisory audits and reports, we aim to evaluate incidents and recommend measures for improvement from a systemic perspective. We believe that supervisory audit reports can be important sources for the municipalities' approach to improving patient safety and for further learning and improvement.