Wednesday 11 March 2026 | 14:30-15:15
Stream: Science

Part 1 - Learning from adverse patient events: openness, trust and a safe climate for speaking up as the foundation of a strong learning culture.

How can we strengthen patient safety through openness, a strong reporting culture, and a safe climate for speaking up? The Norwegian Healthcare Investigation Board’s investigation reports “Reporting culture and learning from adverse patient events” and “Safe patient care requires an open climate for speaking up” show that serious incidents are not always reported or identified, and that fear, uncertainty, and lack of support can make it harder to learn and improve.

This session presents key findings, patient stories, and recommendations from our two reports. Ukom’s reports highlight how leadership, work environment, systems, and culture influence both willingness/readiness and the ability to report adverse events—and how an open climate for speaking up is essential for learning from mistakes and ensuring safe care.

After this session, participants will be able to:

• Understand the connection between reporting culture, a safe speaking-up climate, and patient safety.
• Identify barriers and success factors for openness and learning after adverse events.
• Use reflection questions and improvement tools to strengthen openness and learning in their own organization.

Anne Mette Espe Norwegian Healthcare Investigation Board; Norway
Anette Bakkevig Frøyland

Part 2 - Involvement of next of kin: crucial for patient safety

How can the involvement and support of next of kin strengthen patient safety? Investigations conducted by the Norwegian Healthcare Investigation Board (Ukom) have revealed that the experiences and insights of next of kin are often crucial for safe care pathways, yet the health and care services face challenges in systematic involvement. This session presents key findings, examples, and recommendations from Ukom’s reports, focusing on how health and care services can improve the inclusion of next of kins—before, during, and after serious adverse events. Participants will receive concrete learning points for use in their own improvement work and we will reflect together on how patient safety can be improved through active involvement of next of kin.

After this session, participants will be able to:

• Explain why involvement of next of kin is critical for patient safety.
• Identify barriers and success factors for involving next of kin.
• Apply concrete recommendations and reflection questions in their own quality and improvement work

Synnøve Serigsta Norwegian Healthcare Investigation Board; Norway