{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,18]],"date-time":"2026-10-18T02:31:12Z","timestamp":1792290672385,"version":"4.4.0"},"reference-count":30,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2018,6,15]],"date-time":"2018-06-15T00:00:00Z","timestamp":1529020800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Obstet Gynecol Scand"],"published-print":{"date-parts":[[2018,10]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities.<\/jats:p><\/jats:sec><jats:sec><jats:title>Material and methods<\/jats:title><jats:p>We selected cases investigated by supervision authorities during 2009\u20102013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>During the study period, there were 303\u00a0034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium\u2010sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care.<\/jats:p><\/jats:sec>","DOI":"10.1111\/aogs.13391","type":"journal-article","created":{"date-parts":[[2018,5,28]],"date-time":"2018-05-28T17:55:34Z","timestamp":1527530134000},"page":"1206-1211","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care"],"prefix":"10.1111","volume":"97","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1524-0640","authenticated-orcid":false,"given":"Lars Thomas","family":"Johansen","sequence":"first","affiliation":[{"name":"Norwegian Board of Health Supervision  Oslo Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geir Sverre","family":"Braut","sequence":"additional","affiliation":[{"name":"Stavanger University Hospital and Western Norway University of Applied Sciences  Stavanger Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan Fredrik","family":"Andresen","sequence":"additional","affiliation":[{"name":"Norwegian Board of Health Supervision  Oslo Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P\u00e5l","family":"\u00d8ian","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Faculty of Health Sciences Institute of Clinical Medicine The University Hospital of North Norway The Arctic University of Norway  Troms\u00f8 Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2018,6,15]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2007.023622"},{"key":"e_1_2_8_3_1","first-page":"5370","article-title":"Incidence of adverse events in hospitals. A retrospective study of medical records","volume":"163","author":"Schi\u00f8ler T","year":"2001","journal-title":"Ugeskr Laeger"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.322.7285.517"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2007.025924"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2015-008576"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00404-014-3474-3"},{"key":"e_1_2_8_8_1","unstructured":"Neonatal and perinatal mortality.World Health Organization.2004.http:\/\/apps.who.int\/iris\/bitstream\/10665\/43800\/1\/9789241596145_eng.pdf. Accessed 13 June 2017."},{"key":"e_1_2_8_9_1","unstructured":"Norwegian Institute of Public Health.Medisinsk f\u00f8dselsregister. [Medical Birth Registry of Norway]. In Norwegian.http:\/\/statistikk.fhi.no\/mfr\/. Accessed 10 October 2016."},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1111\/aogs.13172"},{"key":"e_1_2_8_11_1","unstructured":"MBRRACE\u2010UK.Saving lives Improving Mothers\u2019 Care: lay Summary.2014.https:\/\/www.npeu.ox.ac.uk\/downloads\/files\/mbrrace-uk\/reports\/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf. Accessed 20 February 2017."},{"key":"e_1_2_8_12_1","unstructured":"World Health Organization.WHO draft guidelines for adverse events reporting and learning systems.2005.https:\/\/psnet.ahrq.gov\/resources\/resource\/3122. Accessed 13 June 2017."},{"key":"e_1_2_8_13_1","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzn034"},{"key":"e_1_2_8_14_1","unstructured":"Lov om statlig tilsyn med helse\u2010 og omsorgstjenesten m.m (helsetilsynsloven).[The Act on State Supervision of the Health and Care Services etc. (Health Supervision Act).]In Norwegian.https:\/\/lovdata.no\/dokument\/NL\/lov\/1984-03-30-15. Accessed 16 February 2017."},{"key":"e_1_2_8_15_1","unstructured":"Ten Years of Maternity Claims \u2013 An Analysis of NHS Litigation Authority Data \u2013 October 2012.pdf.NHS Litigation Authority.2013.http:\/\/www.nhsla.com\/Safety\/Documents\/Ten. Accessed 13 June 2017."},{"key":"e_1_2_8_16_1","unstructured":"Lov om spesialisthelsetjenesten m.m. (spesialisthelsetjenesteloven) \u00a7 2\u20102. [Act on Specialized Health Services etc. (Specialized Healthcare Act) \u00a7 2\u20102.]In Norwegian.2001.https:\/\/lovdata.no\/dokument\/NL\/lov\/1999-07-02-61. Accessed 16 February 2017."},{"key":"e_1_2_8_17_1","unstructured":"Lov om helsepersonell m.v. (helsepersonelloven) \u00a7 4. [Act on Health Personnel etc. (Health Personnel Act) \u00a7 4.]In Norwegian.2001.https:\/\/lovdata.no\/dokument\/NL\/lov\/1999-07-02-64. Accessed 16 February 2017."},{"key":"e_1_2_8_18_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0412.2012.01409.x"},{"key":"e_1_2_8_19_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2007.01602.x"},{"key":"e_1_2_8_20_1","doi-asserted-by":"publisher","DOI":"10.1080\/00016340701797567"},{"key":"e_1_2_8_21_1","doi-asserted-by":"publisher","DOI":"10.4045\/tidsskr.11.0775"},{"key":"e_1_2_8_22_1","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.12507"},{"key":"e_1_2_8_23_1","doi-asserted-by":"publisher","DOI":"10.1111\/aogs.12606"},{"key":"e_1_2_8_24_1","unstructured":"Spesialisthelsetjenesteloven Kapitel 3.[ Specialized Health Services Act Chapter 3]. In Norwegian.2001.https:\/\/lovdata.no\/dokument\/NL\/lov\/1999-07-02-61#KAPITTEL_3. Accessed 16 February 2017."},{"key":"e_1_2_8_25_1","unstructured":"Norsk gynekologisk forening. Veileder i f\u00f8dselshjelp.2014.[Norwegian Gynecological Association. Guide to childbirth 2014]. (national guidelines in obstetrics). In Norwegian.http:\/\/legeforeningen.no\/Fagmed\/Norsk-gynekologisk-forening\/Veiledere\/Veileder-i-fodselshjelp-2014\/. Accessed 20 June 2017."},{"key":"e_1_2_8_26_1","unstructured":"Helsedirektoratet [Directorate of Health]. Et trygt f\u00f8detilbud \u2013 Kvalitetskrav i f\u00f8dselsomsorgen [A safe maternity service \u2010 quality requirements for maternity care].2010.[Norwegian Directorate for Health. A safe food offer\u2014Quality requirements in childcare 2010.]In Norwegian.https:\/\/helsedirektoratet.no\/retningslinjer\/et-trygt-fodetilbud-kvalitetskrav-til-fodselsomsorgen. Accessed 20 June 2017."},{"key":"e_1_2_8_27_1","doi-asserted-by":"publisher","DOI":"10.1080\/00016340600607149"},{"key":"e_1_2_8_28_1","volume-title":"Virksomhetens interne styring, kapittel 2. Reglement for \u00f8konomistyring i staten, Bestemmelser om \u00f8konomistyring i staten, Fastsatt 12. desember 2003 med endringer senest 14. November 2006. [Internal control of enterprises, Chapter 2. Rules for financial management in the state, Provisions on financial management in the state, Established 12 December 2003 with amendments no later than 14 November 2006.]","author":"Norwegian Ministry of Finance","year":"2006"},{"key":"e_1_2_8_29_1","unstructured":"The Norwegian Board of Health Supervision.2008.Oppsummering av tilsynserfaringer og vurdering av de sm\u00e5 f\u00f8deavdelingene (enheter med under 500 f\u00f8dsler per \u00e5r). [Summary of supervisory experience and assessment of the small maternity departments (units with less than 500 births per year).]In Norwegian.http:\/\/www.helsetilsynet.no\/no\/Publikasjoner\/Brev-hoeringsuttalelser\/Utvalgte-brev-og-horingsuttalelser-tidligere-ar\/Oppsummering-tilsynserfaringer-smaa-foedeavdelingene-under-500-foedsler-aar\/. Accessed 26 June 2017."},{"key":"e_1_2_8_30_1","first-page":"1299","article-title":"Are stipulated requirements for the quality of maternity care complied with?","volume":"137","author":"Johansen LT","year":"2017","journal-title":"Tidskr Nor Legeforen"},{"key":"e_1_2_8_31_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2012.05.010"}],"container-title":["Acta Obstetricia et Gynecologica Scandinavica"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Faogs.13391","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/aogs.13391","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,9,17]],"date-time":"2023-09-17T10:52:25Z","timestamp":1694947945000},"score":1,"resource":{"primary":{"URL":"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/10.1111\/aogs.13391"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,6,15]]},"references-count":30,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2018,10]]}},"alternative-id":["10.1111\/aogs.13391"],"URL":"https:\/\/doi.org\/10.1111\/aogs.13391","archive":["Portico"],"relation":{},"ISSN":["0001-6349","1600-0412"],"issn-type":[{"value":"0001-6349","type":"print"},{"value":"1600-0412","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,6,15]]},"assertion":[{"value":"2017-12-18","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2018-05-13","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2018-06-15","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}