Documentation and disclosure of adverse events that led to compensated patient injury in a Norwegian university hospital.

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. DESIGN A retrospective study of administrative data and patient records. SETTING Trondheim University Hospital, Norway. PARTICIPANTS Patients receiving financial compensation for patient injuries that occurred between the 1 March 2009 and the 31 December 2012. INTERVENTION None. MAIN OUTCOME MEASURES 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. CONCLUSION 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.