The 21 people have all died from drug-related errors in Norwegian hospitals.
A place they thought was safe ended up killing them instead.
This is shown by a larger survey TV 2 has made of all the country’s hospitals.
One of the 21 who lost their lives was 85-year-old Tove. She died last summer after receiving a medicine she was supposed to receive once a week, every day for six days.
– She did not deserve to have two weeks with the hell of pain and the ailments she had. She certainly did not deserve that, her daughter Ragnhild Skari told me.
– The tip of the iceberg
13 out of 19 hospitals have responded to the question of how many have died as a result of incorrect medication and other drug-related errors.
The hospitals from which we do not have figures have either stated that they do not have an overview, or did not have the capacity to ensure the quality of the figures.
There is currently no national overview of adverse events in Norwegian hospitals. This scheme was discontinued in 2019.
By then it had only been operational for seven years.
It is therefore in theory impossible to know how many real incidents are actually involved.
Researcher in community pharmacy at UiO, Anne-Gerd Granås, says there is reason to fear large dark figures.
– There is generally an under-reporting of deviations. So this is just the tip of the iceberg.
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– Extremely important
Most deaths have been registered in the last four years at the hospital in Vestre Viken, with a total of seven deaths.
– It is extremely important that the numbers come on the table, that we go in and learn from the incidents that lead to deaths and try to plug the holes in the system, so that it does not happen again. One death is one too many, says Granås.
Last year alone, three people died at Oslo University Hospital. At the same time, the hospital emphasizes that not all cases are due to incorrect medication at the hospital.
– Incidents that are detected and recorded by our employees have sometimes occurred outside the hospital, and may then apply to conditions at other hospitals, the municipal health service or other external institutions, says Sølvi Andersen, director of quality, patient safety and interaction.
OUS writes that they have a strong focus on improving patient safety.
Over 39,000 events
TV 2 has also asked the hospitals how many of the unwanted patient incidents with medicines had significant consequences for the patient.
This means damage that requires significantly increased intensity of investigation or treatment, permanent loss of function or suffering.
Here, 17 out of 19 hospitals have given their figures.
From 2019 until 2022, there have been 320 incidents at Norwegian hospitals that have resulted in significant consequences for the patient.
TV 2 does not have detailed information about what happened in these incidents.
Overall, more than 39,068 adverse events involving medicines have been registered in the hospitals.
– Big consequences
Granås is clear that it is not possible to compare the hospitals, and that there is thus no one that stands out in a negative sense.
– A high number can also be a good number, because it shows that you have a good reporting culture. A low number also does not mean that there are very few incidents.
REACTS: Anne Gerd Granås is a researcher in community pharmacy. She reacts to the fact that Norway lacks a national overview of adverse patient events. Photo: Bjørn Roger Brevik / TV 2
Patient and user representative in Oslo and Viken, Anna Ryymin, tells TV 2 that mistakes will always occur, as long as people are involved.
– Correct medication is important for patient safety, and incorrect medication can have major consequences for the patient concerned. We are concerned that the hospitals must work in a targeted manner at system level to reduce the number of medication errors, she says.
Must learn from mistakes
Ryymin says that high work pressure, long shifts and overtime can increase the risk.
Patient and user representative in Oslo and Viken, Anna Ryymin. Photo: Ditlev Eidsmo / TV 2
– It is therefore particularly important to focus on good systems and routines that can minimize the risk of errors. It will also be important that good non-conformance systems and a good reporting culture are in place, so that you can learn from the times when things unfortunately go wrong.
– That should not happen
State Secretary in the Ministry of Health and Care Ole Henrik Krat Bjørkholt tells TV 2 that it is extremely regrettable that 21 people have died, as a result of mistakes made in Norwegian hospitals.
– That should not happen. One death, is one death too many. But there are millions of people who are treated with drugs, and when people are involved, mistakes will happen, says Krat Bjørkholt.
MUST LEARN: State Secretary in the Ministry of Health and Care Ole Henrik Krat Bjørkholt says it is very important that we learn from our mistakes. Photo: Pål Martin Rossing / TV 2
– But should one then accept that 21 people die as a result of mistakes being made?
– The objective must be that no people die due to incorrect treatment. But the most important thing is that we have systems that catch the mistakes, and that we don’t have systems that increase the risk of mistakes, says the state secretary.
