ABSTRACT
Analysis of the most severe events in healthcare often reveal that early warnings and weak signals were misunderstood, missed, or discounted by professionals, managers, and organizations with mandate to monitor quality and safety. This is also the case in Norway and some high profile severe adverse events have marked a call for developments in methods that incorporate principles from accident theory, qualitative methods, and user involvement in order to increase understanding of the complex causality. By ways of a qualitative thematic content analysis of national policy documents, we explore the developments in the analysis of the most severe events in the Norwegian healthcare system. The analysis focus on the political and public engagement to change analytical methods, and how methods of the investigation practice have developed the past 10 years in the light of disaster theory and qualitative research methods.
