Why error reporting systems should be voluntary

Doctors, nurses, and pharmacists share a common goal of identifying medical error, understanding its causes, and making system wide changes to reduce medical risks. Error reporting is a primary component of that goal. Recent public policy discussions in the United States have explored the risks and benefits of mandatory and voluntary reporting systems to identify the most effective ways to promote candid disclosure of medical error. 1 2 The Institute for Safe Medication Practices has been a strong and vocal proponent of non-punitive, voluntary error reporting programmes.3 National models exist in the US for both mandatory and voluntary error reporting programmes. The Medication Errors Reporting Program, operated by the United States Pharmacopoeia in cooperation with the Institute for Safe Medication Practices, is a confidential, voluntary medication error reporting programme. About 1000 completed error reports are received each year from clinicians and state boards, but more important than the number of reports is their quality. Each report provides a great deal of information which has allowed us to identify the wide scope of medication safety problems and explore their system based causes. Practical recommendations to prevent reoccurrence are made through a widely distributed newsletter and other educational efforts. The information derived …