What should we report to medical error reporting systems?

The Netherlands is the latest country to announce the development of a national medical error reporting system.1 Australia has had one since 1989, Denmark has one, the UK introduced theirs in 2001, Canada announced their plans in 2003, and the USA has a proliferation of error reporting systems, including several that have been going for a number of years and that have a well developed body of knowledge steering their use and development—for example, the Medical Event Reporting System for Transfusion Medicine (MERS-TM)2 and the US Pharmacopeia’s MEDMARX Reporting System3. Developed western countries do therefore seem to have “bought into” the message that medical error reporting systems are a very “good thing”—although there is little evidence that Johnson’s4 pragmatic cautions have been well considered in setting them up.

The reporting of “medical errors”—whatever they are—is still an embryonic endeavor and, before national and international medical error reporting systems get well under way, some crucial topics—such as defining what we are to report to error reporting systems—should be addressed with clarity. An occasional error reporting system has dealt with ambiguity over what needs to be reported by adopting a list of explicitly defined events “that should never happen”,5 but most are far less precise. Hopefully, the national medical error reporting systems of different countries will ultimately (if not initially) use the same definitions. We raise some issues here that expose the complexity of defining “medical error” and demonstrate just how peculiar, unnatural, and un-useful are some of the terms and definitions in current use.

Starting from first principles, it seems clear that a medical error reporting system should hold reports …