In 2003, 1 810 adverse events were registered, that involved a duty to report to the Norwegian Board of Health in the counties. The number of reports of injuries to patients in 2003 has increased slightly, compared to the number during the last few years.

 

The material does not provide adequate information about what measures were taken by the organizations to prevent adverse events happening and being repeated. It is pointed out that, according to the legal requirements on internal control, responsibility for following up adverse events in the health services lies with the institution where the event occurred.

 

The Norwegian Board of Health is concerned that the reports represent only the tip of the iceberg, with regard to the occurrence of injuries to patients in specialist health services. The Norwegian Board of Health believes that the health institutions that send in the most reports of adverse events are those institutions that have better-functioning quality control systems than those institutions who report few or no events.