Mandatory state-based error-reporting systems: current and future prospects.

Abstract

The magnitude of medical errors documented in the 1999 Institute of Medicine report "To Err Is Human" encouraged health care leaders across the country to evaluate and improve current systems of care. To aid in this effort, the authors recommended and provided guidelines for establishing state-based mandatory error-reporting systems. This repository for medical errors would allow experts to categorize, trend, and analyze data, generating institutional responsibility and increasing knowledge about medical mistakes. To be effective, these systems must employ efficient data collection methods, techniques for analysis, and feedback mechanisms. They must also engage institutional leaders in fostering a culture of safety and encourage multidisciplinary collaboration to learn from mistakes and improve microsystem-level processes. A review of current systems reveals extreme variation across states in each of these areas. However, initial successes do exist, suggesting the true potential of these systems and the need for continued evaluation as systems progress in future efforts.