Since 1937, after a catastrophic accident at a Stockholm hospital where four persons died, all care-giving organisations in Sweden are compelled to report all serious adverse events to the National Board of Health and Welfare. This is called the "Lex Maria" procedure, named after the hospital in question.
The number of cases reported by the County Council of Östergötland is shown in the figure below. We believe that the increase is due to a change in attitude towards reporting among healthcare personnel.
Blue - Reported to National Board Health and Welfare
Red - Root Cause Analysis
Under the supervision of the CMO most cases are subjected to a root cause analysis where systemic causes are looked for. Then a report is sent to the National Board of Health and Welfare together with statements of all involved staff. An answer is received within a couple of months with proposed actions for improvement. The CMO then confirms that these are implemented at the department in question.