• Torsten Mossberg.
• Socialstyrelsens regionala tillsynsenhet i Stockholm. torsten.mossberg@sos.se
• Lakartidningen. 2003 Nov 20; 100 (47): 3856-9.

AbstractDeviations from the normal course of care occur in about one tenth of all hospitalizations. Investigation and analysis of an adverse incident should be systematic. The investigation should be conducted by a team within the organization. Material to be collected includes, aside from written reports, interviews of all involved parties. The investigation should not focus on individuals, but should concentrate primarily on organizational reasons for the incident. The affected patient (and his relatives) should always be informed as to what has happened, should be provided an explanation and, when appropriate, an apology. The patient must be provided an opportunity to describe the incident in his or her own words. Staff members involved in the incident often need professional psychosocial support. A climate of safety which would allow candid review and discussion concerning adverse incidents and errors must be engendered in health care. Awareness of legalities and the manner with which the Swedish system manages adverse incidents must be enhanced.

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