title: Documentation and disclosure of adverse events that led to compensated patient injury in a Norwegian university hospital.
abstract: OBJECTIVE
  Primarily, to describe to what extent patient injury, compensated by a national system of patient compensation, was reported in the mandatory incident-reporting system and documented in the patient's medical records. Secondarily, to investigate whether there is documentation of patient disclosure of the injury and documentation that the patient was informed of his or her right to apply for economic compensation.
  
  
  METHODS
  A retrospective study of administrative data and patient records.
  
  
  METHODS
  Trondheim University Hospital, Norway.
  
  
  METHODS
  Patients receiving financial compensation for patient injuries that occurred between the 1 March 2009 and the 31 December 2012.
  
  
  METHODS
  None.
  
  
  METHODS
  Documentation of injury, type of injury and consequence for the patient. Patient disclosure in medical records. Prevalence of incident reports.
  
  
  RESULTS
  20.4% of all compensated patient injuries and 26.3% of serious compensated patient injuries, defined as death or a disability of >15%, had been reported. The injury was documented in the patient's medical records in 90.7% of cases, but as an adverse event causing patient injury in only 3.4%. Documentation about patient disclosure was missing in 32.1% of cases, and giving information of his or her legal right to claim compensation was documented in 21.6% of cases.
  
  
  CONCLUSIONS
  Underreporting and nondisclosure of patient injuries remain a problem, despite a mandatory reporting system. Helping physicians and surgeons recognize adverse events, reporting them and discussing them with patients should be a priority for hospitals and medical schools.
authors.affiliation: Faculty of Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Susanne Skjervold
authors.initials: SS
authors.lastname: Smeby
authors.affiliation: Department of Public Health and General Practice, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Roar
authors.initials: R
authors.lastname: Johnsen
authors.affiliation: Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Gudmund
authors.initials: G
authors.lastname: Marhaug
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004282:Documentation; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D008297:Male; D008485:Medical Audit; D019300:Medical Errors / Q000009:adverse effects* / Q000191:economics; D008875:Middle Aged; D009664:Norway; D012189:Retrospective Studies; D014342:Truth Disclosure; D055815:Young Adult
keywords: incident reporting systems; patient disclosure; patient injury; safety management