Norway. Improving Patient Safety in Norwegian Hospitals through a Standardized Approach toward the Measurement and Monitoring of Adverse Events

Ellen Tveter Deilkas, Geir Bukholm, and Anen Ringard

CONTENTS

Background..........................................................................................................222

Why Did Norway Choose to Monitor Adverse Events in All Hospitals? ....223

How the Monitoring Was Mandated and Organized....................................224

Why Did the Monitoring of Adverse Events Succeed?.................................224

Conclusion............................................................................................................226

Background

In Norway, as in most European countries, health coverage is statutory and opting out is not permitted. Patients have no discretion over what is covered, but they are allowed to select their healthcare provider. Healthcare provision is organized at two hierarchical levels: municipal (local) and national. Municipal authorities are responsible for primary care and enjoy a great deal of freedom in organizing health services.

Specialist care is the national government's responsibility. The National Ministry of Health and Care Services owns four regional health authorities (RHAs), which in turn own hospital trusts. The ministry governs through directives, annual budgets, and meetings. Annual directives from the Directorate of Health—a subordinate body of the ministry involved in planning and implementing healthcare policies—supplement the ministry's directives (Ringard et al., 2013).

The Norwegian healthcare system has been through substantial changes in recent decades (Ringard et al., 2013). Currently, several large-scale changes are either being implemented or evaluated by the government. On January 1, 2016, a major reform took place in the central health administration system, merging a number of public agencies into fewer and larger units. A political initiative addressing the relationship between the national government and the RHAs is also underway. Locally, the number of hospital trusts providing acute/emergency surgical care is being re-evaluated, and municipal reform, including a reduction in the number of municipalities, is under consideration.

In addition to these potential structural reforms, there is ongoing debate over service content. There has been discussion about priority setting (i.e., how to best allocate scarce health resources), and initiatives aimed at enhancing patients' choice of hospital provider are being implemented. Increased attention is also being paid to issues relating to quality and patient safety within the public health services (Deilkas et al., 2015b).

Prevention and follow-up of adverse events (AEs) in health and care services are among the most visible quality and safety issues on the health policy agenda. In November 2015, an expert committee, appointed by the ministry in 2013, published a public report on AEs. According to its mandate, the committee was to review how AEs and suspicion of legal violations within the health and care services are subsequently followed up. Thus, the report contains both a review of the current situation on AEs and assessments, as well as policy recommendations (Ministry of Health and Care Services [Norway], 2015).

There are several sources of information for AEs in Norwegian hospitals. Death and severe patient injuries are reported to the National Board of Health Supervision. The board received 1271 reports between June 1, 2010 and December 31, 2014. In 2014, of 414 reported incidents, 303 involved deaths and 63 involved severe injuries. The National Reporting and Learning

System (NRLS), established in 2012, also receives reports from hospital trusts on the number and type of AEs and "near misses." The NRLS received about 9500 reports in 2014, of which almost a fifth were classified as severe injuries or leading to death. The System for Patient Injury Compensation (NPE) also provides information on AEs. In 2014, more than 60% of all individual patient claims came from the four RHAs (total number of claims was 5217) (Ministry of Health and Care Services [Norway], 2015). Since 2005, there has also been a national registry for incidence of surgical site infections.

While all of these systems provide valuable information, it is impossible to obtain an estimate of the national level of AEs based solely upon these sources. However, quantitative and standardized information about AEs and harm in Norwegian hospitals is available through medical record review using the Global Trigger Tool (GTT) (Deilkas et al., 2015a; Griffin and Resar, 2009). Our success story examines the development of Norway's national system for monitoring AEs. The monitoring is based on the GTT method, which the Institute for Healthcare Improvement developed to standardize and streamline medical record reviews. The records of 10 adult patients are randomly selected from hospital discharge lists every fortnight. Records are reviewed with criteria (triggers) indicating risks of AEs. Results are analyzed in time series with statistical process control.

 
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