Table 2 Documentary evidence identified, included and analyzed

• Patient- and informal caregivers’ perspectives following serious incidents [35].

• The Act of 2 July 1999 No. 64 relating to Health Personnel (the Health Personnel Act) [42].

• The Act of 2 July 1999 No. 61 relating to the specialized healthcare services (the Specialized Healthcare Services Act) [41].

• The Act of 15 December 2017 No. 107 relating to governmental supervision with the healthcare services (The Health Supervision Act) [40].

• Guidelines for inspection conducted by the County Governor level- Appendix 2 [52].

• Recommendations related to stakeholder involvement in external inspection [53].

• Information to managers and health professionals regarding onsite inspection [54].

• Annual Report 2021 Norwegian Board of Health Supervision [39].

• Onsite inspection as method following reports of serious incidents [55].

• Guidelines - reports delegated to the County Governors from the NBHS [56].

• Response letter from the NBHS to the Consultative Committee responsible for assessing the incident reporting regime in Norway [57].

• Reminder: letter from the NBHS to the health care trusts and municipalities [58].

• Additional external inspection follow-up following reports of serious incidents [59].

• External inspection follow-up of violations [60].

• Follow up by the organization and feedback to the County Governor [61].

• Priorities and assessment regarding external inspection [62]

• Reception and clarification - Guidelines for the County Governor proceedings of incidents [63]

• Delegation to the County Governor of notifications related to serious incidents [64]

• Transfer to organizations/health professionals [65].