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Mandatory reporting systems should focus on the identification of serious adverse events attributable to error. Adverse events are deaths or serious injuries resulting from a medical intervention.1 Not all, but many, adverse events result from errors. Mandatory reporting systems generally require health care organizations to submit reports on all serious adverse events for two reasons: they are easy to identify and hard to conceal. But it is only after careful analysis that the subset of reports of particular interest, namely those attributable to error, are identified and follow-up action can be taken.
The committee also believes that the focus of mandatory reporting system should be narrowly defined. There are significant costs associated with reporting systems, both costs to health care organizations and the cost of operating the oversight program. Furthermore, reporting is useful only if it includes analysis and follow-up of reported events. A more narrowly defined program has a better chance of being successful.
A standardized reporting format is needed to define what ought to be