Independent Safety Investigation in Norway – the Work of UKOM From a Risk Management Perspective.

The Norwegian Healthcare Investigation Board (UKOM) is a relatively new government body tasked with its mission of conducting independent safety investigation of serious incidents in the healthcare services. This study was developed prior to this proposal and aims to explore how UKOM's work has evolved from a risk management perspective, and how UKOM employees experience the processes of investigation and analysis, resulting in investigation reports. The study also aims to explore how investigators perceive investigations to influencing the healthcare system and contributing to system change and learning. The study employs an explorative design with a qualitative approach including semi-structured individual interviews with 11 participants from UKOM, conducted between January and April 2023. The study revealed that the learning potential from serious incidents is a key factor in selecting issues and events for investigation. Results showed that the composition of interdisciplinary investigator teams is an important resource, bringing diverse perspectives to the process and facilitating mutual learning within the team. The study also demonstrated that the legally mandated focus on learning, not punishment, fosters transparency and a safe space for sharing stories, thoughts, and opinions for both healthcare professionals and next of kin.

Keywords: UKOM, Safety investigation, Risk management, Safety, Learning, Improvement.