Journal Reporting of Medical Errors: The Wisdom of Solomon, the Bravery of Achilles, and the Foolishness of Pan

摘要

Medical errors may result from lapses in judgment or lack of prudent care by individualnphysicians, from system errors inherent in the medical-care delivery model or, more frequently,nfrom a combination of the two. Medical error reporting is a sensitive topic for physicians,ninstitutions, and patients. The veil of secrecy that surrounds medical errors deprives health-carenpractitioners of knowledge that may help prevent similar adverse outcomes for patients in thenfuture. Although reporting individual medical errors to involved patients is obligatory by mostnprofessional codes of conduct for physicians, no laws or professional society guidelines mandatenwidespread reporting of errors to professional colleagues. Furthermore, reports of medicalnerrors in peer-reviewed journals are extremely rare. In 2000, the Joint Commission fornAccreditation of Healthcare Organizations described systemic medical errors as “fundamentallynan information problem” and called for the development of programs to collect and analyzenmedical error data. In this review, we define medical errors and detail common motivations andnbarriers to publication of error reports. We propose a model for confidential error communica-ntion and describe US legislation designed to improve patient safety and establish nationwidenprograms for error disclosure and analysis. (CHEST 2007; 131:890–896)