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Reporting Culture and Learning from Adverse Patient Events 

In this report, the Norwegian Healthcare Investigation Board (Ukom) focuses on adverse events in hospitals, and how these can be detected, reported in internal quality systems, and/or notified to the authorities. The purpose of reporting adverse events in healthcare and care services is for these to be reviewed and used for future learning, to prevent the same type of event from happening again. Therefore, reporting deviations and subsequent analysis of adverse events are part of the improvement culture at most workplaces. 

Ukom has received concern reports from both relatives and healthcare personnel that adverse events are not always reported or notified. If events are not detected and reported, the organization may miss out on important learning and information in the improvement work. 

Employees may find it difficult to report events for several reasons. In the report, we use a staircase model to illustrate the steps from detecting an adverse event, through considering reporting, initiating the report, and to the manager's handling of the report with analysis and improvement measures. 

A work environment with psychological safety at the workplace where there is a culture for reporting deviations and adverse events without fear of sanctions is a prerequisite for a good reporting culture. Employees' perception of what has actually happened, the manager's follow-up on adverse events, and practical aspects of the reporting system itself also affect what is reported or notified. 

One of the prerequisites for learning from an event is that we manage to see that something could have been done differently. Only then does the event have learning value. In healthcare and care services, as well as in other sectors, punishment and sanctions do not promote learning. Therefore, Ukom also discusses in this report whether the condition for notifying the authorities of deaths and serious patient harm should be clarified. The concept of "foreseeable risk" is interpreted differently and can stand in the way of the learning potential of an event. 

The role of the patient and relatives and their right to information in serious events are also highlighted. Ukom sees that there can be differing views on whether a serious event is an expected complication or patient harm, and that this affects communication. Again, we see that the foreseeable-risk concept is unfortunate and can give patients and relatives a feeling of lack of openness. 

The report addresses legislators, Ministry of Health and Care Services, regulatory authorities, patients and relatives, corporate boards, as well as leaders and employees in the health and care services. 

The translation from Norwegian to English is based in AI. Ukom has reviewed, edited and quality assured the translation.