When the Institute of Medicine (IOM) issued To Err Is Human,1the recommendation to expand reporting of serious adverse eventsand medical errors, particularly mandatory reporting, receivedthe most attention and sparked controversy.2 The American MedicalAssociation and the American Hospital Association raised strongobjections, claiming that mandatory reporting would increaseliability and drive reporting underground.3 Clearly, the reportstruck a nerve.
Although the response of the American Medical Association reflectedsome confusion about the IOM's advice the call for mandatoryreporting was directed at hospitals, not physicians the discussion brought to the surface the unresolved conflictbetween . . . [Full Text of this Article]
The Role of Reporting
Voluntary External Reporting Systems
Mandatory External Reporting Systems
Reasons for the Inadequacy of Current Reporting Systems
Greene, S B, Williams, C E, Pierson, S, Hansen, R A, Carey, T S
(2010). Medication error reporting in nursing homes: identifying targets for patient safety improvement. Qual Saf Health Care
: qshc.2008.031260v1-qshc.2008.031260
[Abstract][Full Text]
Garrouste-Orgeas, M., Timsit, J. F., Vesin, A., Schwebel, C., Arnodo, P., Lefrant, J. Y., Souweine, B., Tabah, A., Charpentier, J., Gontier, O., Fieux, F., Mourvillier, B., Troche, G., Reignier, J., Dumay, M. F., Azoulay, E., Reignier, B., Carlet, J., Soufir, L., on behalf of the OUTCOMEREA Study Group,
(2010). Selected Medical Errors in the Intensive Care Unit: Results of the IATROREF Study: Parts I and II. Am. J. Respir. Crit. Care Med.
181: 134-142
[Abstract][Full Text]
Snijders, C, van der Schaaf, T W, Klip, H, van Lingen W P F Fetter, R A, Molendijk, A, on behalf of the NEOSAFE study group,
(2009). Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis. Qual Saf Health Care
18: 486-491
[Abstract][Full Text]
Reid, M., Estacio, R., Albert, R.
(2009). Injury and Death Associated With Incidents Reported to the Patient Safety Net. American Journal of Medical Quality
24: 520-524
[Abstract]
Panesar, S. S, Cleary, K., Sheikh, A.
(2009). Reflections on the National Patient Safety Agency's database of medical errors. JRSM
102: 256-258
[Full Text]
Snijders, C, van Lingen, R A, Klip, H, Fetter, W P F, van der Schaaf, T W, Molendijk, H A, on behalf of the NEOSAFE study group,
(2009). Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. Arch. Dis. Child. Fetal Neonatal Ed.
94: F210-F215
[Abstract][Full Text]
Bilimoria, K. Y., Kmiecik, T. E., DaRosa, D. A., Halverson, A., Eskandari, M. K., Bell, R. H. Jr, Soper, N. J., Wayne, J. D.
(2009). Development of an Online Morbidity, Mortality, and Near-Miss Reporting System to Identify Patterns of Adverse Events in Surgical Patients. Arch Surg
144: 305-311
[Abstract][Full Text]
Sofaer, N, Thiessen, C, Goold, S D, Ballou, J, Getz, K A, Koski, G, Krueger, R A, Weissman, J S
(2009). Subjects' views of obligations to ensure post-trial access to drugs, care and information: qualitative results from the Experiences of Participants in Clinical Trials (EPIC) study. J. Med. Ethics
35: 183-188
[Abstract][Full Text]
Benn, J, Koutantji, M, Wallace, L, Spurgeon, P, Rejman, M, Healey, A, Vincent, C
(2009). Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care
18: 11-21
[Abstract][Full Text]
Paradis, A. R., Stewart, V. T., Bayley, K. B., Brown, A., Bennett, A. J.
(2009). Excess Cost and Length of Stay Associated With Voluntary Patient Safety Event Reports in Hospitals. American Journal of Medical Quality
24: 53-60
[Abstract]
Jha, A. K, Laguette, J., Seger, A., Bates, D. W
(2008). Can Surveillance Systems Identify and Avert Adverse Drug Events? A Prospective Evaluation of a Commercial Application. J Am Med Inform Assoc
15: 647-653
[Abstract][Full Text]
Stern, Z., Katz-Navon, T., Naveh, E.
(2008). The Influence of Situational Learning Orientation, Autonomy, and Voice on Error Making: The Case of Resident Physicians. Management Science
54: 1553-1564
[Abstract]
Hoffmann, B, Beyer, M, Rohe, J, Gensichen, J, Gerlach, F M
(2008). "Every error counts": a web-based incident reporting and learning system for general practice. Qual Saf Health Care
17: 307-312
[Abstract][Full Text]
Braithwaite, J., Westbrook, M., Travaglia, J.
(2008). Attitudes toward the large-scale implementation of an incident reporting system. Int J Qual Health Care
20: 184-191
[Abstract][Full Text]
Wu, J.-H., Shen, W.-S., Lin, L.-M., Greenes, R. A., Bates, D. W.
(2008). Testing the technology acceptance model for evaluating healthcare professionals' intention to use an adverse event reporting system. Int J Qual Health Care
20: 123-129
[Abstract][Full Text]
Hicks, R. W., Sikirica, V., Nelson, W., Schein, J. R., Cousins, D. D.
(2008). Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm
65: 429-440
[Abstract][Full Text]
Kaldjian, L. C., Jones, E. W., Wu, B. J., Forman-Hoffman, V. L., Levi, B. H., Rosenthal, G. E.
(2008). Reporting Medical Errors to Improve Patient Safety: A Survey of Physicians in Teaching Hospitals. Arch Intern Med
168: 40-46
[Abstract][Full Text]
Garbutt, J., Waterman, A. D., Kapp, J. M., Dunagan, W. C., Levinson, W., Fraser, V., Gallagher, T. H.
(2008). Lost Opportunities: How Physicians Communicate About Medical Errors. Health Aff (Millwood)
27: 246-255
[Abstract][Full Text]
Mattie, A. S., Ben-Chitrit, R.
(2007). Patient Safety Legislation: A Look at Health Policy Development. Policy Politics Nursing Practice
8: 251-261
[Abstract]
Henneman, E. A.
(2007). Unreported Errors in the Intensive Care Unit: A Case Study of the Way We Work. Crit Care Nurse
27: 27-34
[Full Text]
Jacobs, J. P., Jacobs, M. L., Mavroudis, C., Maruszewski, B., Tchervenkov, C. I., Lacour-Gayet, F. G., Clarke, D. R., Yeh, T. Jr, Walters, H. L. III, Kurosawa, H., Stellin, G., Ebels, T., Elliott, M. J., Vener, D. F., Barach, P., Benavidez, O. J., Bacha, E. A.
(2007). What is Operative Morbidity? Defining Complications in a Surgical Registry Database. Ann. Thorac. Surg.
84: 1416-1421
[Full Text]
Snijders, C, van Lingen, R A, Molendijk, A, Fetter, W P F
(2007). Incidents and errors in neonatal intensive care: a review of the literature. Arch. Dis. Child. Fetal Neonatal Ed.
92: F391-F398
[Abstract][Full Text]
Pierson, S., Hansen, R., Greene, S., Williams, C., Akers, R., Jonsson, M., Carey, T.
(2007). Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. Qual Saf Health Care
16: 297-302
[Abstract][Full Text]
Evans, S. M, Smith, B. J, Esterman, A., Runciman, W. B, Maddern, G., Stead, K., Selim, P., O'Shaughnessy, J., Muecke, S., Jones, S.
(2007). Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care
16: 169-175
[Abstract][Full Text]
Williams, M V
(2007). Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br. J. Radiol.
80: 297-301
[Abstract][Full Text]
Stebbing, C., Wong, I. C K, Kaushal, R., Jaffe, A.
(2007). The role of communication in paediatric drug safety. Arch. Dis. Child.
92: 440-445
[Abstract][Full Text]
Holden, R. J., Karsh, B.-T.
(2007). A Review of Medical Error Reporting System Design Considerations and a Proposed Cross-Level Systems Research Framework. Human Factors: The Journal of the Human Factors and Ergonomics Society
49: 257-276
[Abstract]
(2007). Medical Errors: Focusing More on What and Why, Less on Who. J Oncol Pract
3: 66-70
[Full Text]
Neale, G., Vincent, C., Darzi, S. A.
(2007). The problem of engaging hospital doctors in promoting safety and quality in clinical care. The Journal of the Royal Society for the Promotion of Health
127: 87-94
[Abstract]
Haller, G., Myles, P. S, Stoelwinder, J., Langley, M., Anderson, H., McNeil, J.
(2007). Integrating Incident Reporting into an Electronic Patient Record System. J Am Med Inform Assoc
14: 175-181
[Abstract][Full Text]
van Beuzekom, M, Akerboom, S P, Boer, F
(2007). Assessing system failures in operating rooms and intensive care units. Qual Saf Health Care
16: 45-50
[Abstract][Full Text]
Katz-Navon, T., Naveh, E., Stern, Z.
(2007). The moderate success of quality of care improvement efforts: three observations on the situation. Int J Qual Health Care
19: 4-7
[Abstract][Full Text]
Garbutt, J., Brownstein, D. R., Klein, E. J., Waterman, A., Krauss, M. J., Marcuse, E. K., Hazel, E., Dunagan, Wm. C., Fraser, V., Gallagher, T. H.
(2007). Reporting and Disclosing Medical Errors: Pediatricians' Attitudes and Behaviors. Arch Pediatr Adolesc Med
161: 179-185
[Abstract][Full Text]
Davis, T. C., Wolf, M. S., Bass, P. F. III, Thompson, J. A., Tilson, H. H., Neuberger, M., Parker, R. M.
(2006). Literacy and Misunderstanding Prescription Drug Labels. ANN INTERN MED
145: 887-894
[Abstract][Full Text]
Ochroch, E. A., Russell, M. W., Hanson, W. C. III, Devine, G. A., Cucchiara, A. J., Weiner, M. G., Schwartz, S. J.
(2006). The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor.. Anesth. Analg.
102: 868-875
[Abstract][Full Text]
Ashcroft, D M, Morecroft, C, Parker, D, Noyce, P R
(2006). Likelihood of reporting adverse events in community pharmacy: an experimental study. Qual Saf Health Care
15: 48-52
[Abstract][Full Text]
Escoto, K. H., Karsh, B.-T., Beasley, J. W.
(2006). Multiple User Considerations and Their Implications in Medical Error Reporting System Design. Human Factors: The Journal of the Human Factors and Ergonomics Society
48: 48-58
[Abstract]
McIntosh, S. T., Petropoulos, J. B.
(2005). Using data from automated dispensing units to identify adverse drug reactions. Am J Health Syst Pharm
62: 2397-2400
[Full Text]
Wood, K. E., Nash, D. B.
(2005). Mandatory State-Based Error-Reporting Systems: Current and Future Prospects. American Journal of Medical Quality
20: 297-303
[Abstract]
Roumm, A. R., Sciamanna, C. N., Nash, D. B.
(2005). Health Care Provider Use of Private Sector Internal Error-Reporting Systems. American Journal of Medical Quality
20: 304-312
[Abstract]
Savage, S. W., Schneider, P. J., Pedersen, C. A.
(2005). Utility of an online medication-error-reporting system. Am J Health Syst Pharm
62: 2265-2270
[Abstract][Full Text]
Jacobson, P. D., Bloche, M. G.
(2005). Improving Relations Between Attorneys and Physicians. JAMA
294: 2083-2085
[Full Text]
Armitage, G.
(2005). Litigious culture - keep your counsel. Journal of Research in Nursing
10: 487-489
Shaw, R, Drever, F, Hughes, H, Osborn, S, Williams, S
(2005). Adverse events and near miss reporting in the NHS. Qual Saf Health Care
14: 279-283
[Abstract][Full Text]
Naveh, E., Katz-Navon, T., Stern, Z.
(2005). Treatment Errors in Healthcare: A Safety Climate Approach. Management Science
51: 948-960
[Abstract]
Schmidek, J M, Weeks, W B
(2005). Relationship between tort claims and patient incident reports in the Veterans Health Administration. Qual Saf Health Care
14: 117-122
[Abstract][Full Text]
Holzmueller, C. G, Pronovost, P. J, Dickman, F., Thompson, D. A, Wu, A. W, Lubomski, L. H, Fahey, M., Steinwachs, D. M, Engineer, L., Jaffrey, A., Morlock, L. L, Dorman, T.
(2005). Creating the Web-based Intensive Care Unit Safety Reporting System. J Am Med Inform Assoc
12: 130-139
[Abstract][Full Text]
Boxwala, A. A, Dierks, M., Keenan, M., Jackson, S., Hanscom, R., Bates, D. W, Sato, L.
(2004). Organization and Representation of Patient Safety Data: Current Status and Issues around Generalizability and Scalability. J Am Med Inform Assoc
11: 468-478
[Abstract][Full Text]
Tuttle, D, Holloway, R, Baird, T, Sheehan, B, Skelton, W K
(2004). Electronic reporting to improve patient safety. Qual Saf Health Care
13: 281-286
[Abstract][Full Text]
Morimoto, T, Gandhi, T K, Seger, A C, Hsieh, T C, Bates, D W
(2004). Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care
13: 306-314
[Abstract][Full Text]
Pronovost, P. J., Wu, A. W., Sexton, J. B.
(2004). Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit. ANN INTERN MED
140: 1025-1033
[Abstract][Full Text]
Arah, O A, Klazinga, N S
(2004). How safe is the safety paradigm?. Qual Saf Health Care
13: 226-232
[Abstract][Full Text]
Clark, P. A.
(2004). Medication Errors in Family Practice, in Hospitals and After Discharge from the Hospital An Ethical Analysis. J Law Med Ethics
32: 349-357
Suresh, G., Horbar, J. D., Plsek, P., Gray, J., Edwards, W. H., Shiono, P. H., Ursprung, R., Nickerson, J., Lucey, J. F., Goldmann, D., for the NICQ2000 and NICQ2002 investigators of the,
(2004). Voluntary Anonymous Reporting of Medical Errors for Neonatal Intensive Care. Pediatrics
113: 1609-1618
[Abstract][Full Text]
McCafferty, M. H., Polk, H. C. Jr
(2004). Addition of "Near-Miss" Cases Enhances a Quality Improvement Conference. Arch Surg
139: 216-217
[Abstract][Full Text]
Small, S. D.
(2004). Medical Device-Associated Safety and Risk: Surveillance and Stratagems. JAMA
291: 367-370
[Full Text]
Levy, F. H.
(2004). Excess Hospitalization Costs Attributable to Medical Injuries. AAP Grand Rounds
11: 7-8
[Full Text]
Zhan, C, Miller, M R
(2003). Administrative data based patient safety research: a critical review. Qual Saf Health Care
12: ii58-63
[Abstract][Full Text]
Zhan, C., Miller, M. R.
(2003). Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization. JAMA
290: 1868-1874
[Abstract][Full Text]
Herndon, J. H.
(2003). One More Turn of the Wrench. JBJS
85: 2036-2048
[Full Text]
Sirio, C. A., Segel, K. T., Keyser, D. J., Harrison, E. I., Lloyd, J. C., Weber, R. J., Muto, C. A., Webster, D. G., Pisowicz, V., Feinstein, K. W.
(2003). Pittsburgh Regional Healthcare Initiative: A Systems Approach For Achieving Perfect Patient Care. Health Aff (Millwood)
22: 157-165
[Abstract][Full Text]
Frank, S., Holloway, R.
(2003). Medical errors on an inpatient neurology service. Neurology
61: 254-257
[Abstract][Full Text]
Berwick, D. M.
(2003). Errors Today and Errors Tomorrow. NEJM
348: 2570-2572
[Full Text]
Minear, M. N., Sutherland, J.
(2003). Medical Informatics-A Catalyst for Operating Room Transformation. SURG INNOV
10: 71-78
[Abstract]
Woolf, A., Litovitz, T., Leape, L. L.
(2003). Reporting of Adverse Events. NEJM
348: 1410-1411
[Full Text]
Volpp, K. G.M., Grande, D.
(2003). Residents' Suggestions for Reducing Errors in Teaching Hospitals. NEJM
348: 851-855
[Full Text]
Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., Levinson, W.
(2003). Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors. JAMA
289: 1001-1007
[Abstract][Full Text]
Burke, J P
(2003). COMMENTARY. Qual Saf Health Care
12: 63-64
[Full Text]