Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan

Abstract

Medical errors may result from lapses in judgment or lack of prudent care by individual physicians, from system errors inherent in the medical-care delivery model or, more frequently, from a combination of the two. Medical error reporting is a sensitive topic for physicians, institutions, and patients. The veil of secrecy that surrounds medical errors deprives health-care practitioners of knowledge that may help prevent similar adverse outcomes for patients in the future. Although reporting individual medical errors to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. Furthermore, reports of medical errors in peer-reviewed journals are extremely rare. In 2000, the Joint Commission for Accreditation of Healthcare Organizations described systemic medical errors as "fundamentally an information problem" and called for the development of programs to collect and analyze medical error data. In this review, we define medical errors and detail common motivations and barriers to publication of error reports. We propose a model for confidential error communication and describe US legislation designed to improve patient safety and establish nationwide programs for error disclosure and analysis.