Reporting of medical errors: time for a reality check

Earlier this summer an expert group chaired by the Chief Medical Officer in the UK produced a comprehensive and thoughtful analysis of the current unacceptable state of identifying, analysing, and learning from medical mishaps.1 Although this report, provocatively named An Organisation with a Memory, applies specifically to the UK National Health Service (NHS), its analysis—and prescriptions—apply to health organisations the world over. The report embraces the insight from industrial safety research pioneered in the UK by Reason and others that human errors typically result, not from carelessness or incompetence, but from systems failures that are sometimes complex and difficult to analyse and correct.2

The call for better reporting, a more open culture, better mechanisms for ensuring that necessary changes are made, and a much wider appreciation of the value of the systems approach is welcome. The cornerstone of the recommendations is a greatly enhanced system of national reporting of adverse events. Although the benefits of such a programme seem self-evident, two questions must be addressed before proceeding with such a plan—namely: “Why aren't these events being reported now?” and “What would be the cost of such a system?”

Charles Billings, architect of the highly successful Aviation Safety Reporting System in the USA, has pointed out that there are two major reasons why people don't report adverse events: fear and lack of belief that reporting will lead to improvement.3 Fear is multidimensional—fear of embarrassment, fear of punishment of self, fear of punishment of others, fear …