Reporting of patient injuries--the supervisory authority's use of sanctions

When health care leads to serious adverse events that result in (or could have resulted in) injuries to patients, hospitals are obliged to report this to The Norwegian Board of Health Supervision in the Counties. The purpose of this study was to quantify how many cases were instigated on the basis of reports sent to the supervisory authority and to what extent health personnel were sanctioned because of them. Reports received by The Norwegian Board of Health Supervision in the Counties (in the period 1.07.2002- 30.06.2007) and cases instigated by the National Board of Health (on basis of the reports) in the period 1.01.2003-31.12.2007. The supervisory authority received 9268 reports in the period. 443 (4.7 %) of them led to instigation of cases and 19 of these (2 of the reports) resulted in formal sanctioning of health personnel (13 of the sanctions were to physicians; 12 received a warning and one lost her specialist license). The Board of Health Supervision seems to have quite different thresholds for instigating report-based cases in the various counties. Health personnel seem to have little reason to fear that reports on (potential) adverse events will lead to sanctions from the supervisory authority. However, the Board of Health Supervision in the Counties should have a more predictable practice concerning instigation of report-based cases.