Reporting of Adverse Events

Systems for reporting adverse events can reduce medical errors by uncovering remediable problems in processes of care; however, current reporting systems are neither widely used nor highly effective. Reporting systems work best when they are confidential and easy to use, provide expert analysis of reports, and give timely feedback. When the Institute of Medicine (IOM) issued To Err Is Human, 1 the recommendation to expand reporting of serious adverse events and medical errors, particularly mandatory reporting, received the most attention and sparked controversy. 2 The American Medical Association and the American Hospital Association raised strong objections, claiming that mandatory reporting would increase liability and drive reporting underground. 3 Clearly, the report struck a nerve. Although the response of the American Medical Association reflected some confusion about the IOM's advice — the call for mandatory reporting was directed at hospitals, not physicians — the discussion brought to the surface the unresolved conflict between . . .