ASHP statement on reporting medical errors.

The incidence of death and serious harm caused by mistakes and accidents in health care is unacceptable. This serious public health problem merits top-priority national attention. Addressing this issue will require major reforms and sizable investment of resources throughout the health care system, including the medication use process, which is a particular focus of the American Society of Health-System Pharmacists (ASHP). ASHP believes that the following steps should be taken as part of a comprehensive national solution to the problem: (1) The establishment of a standardized, uniform nationwide system (with the characteristics noted below) of mandatory reporting of adverse medical events that cause death or serious harm, (2) continued development and strengthening of systems for voluntary reporting of medical errors, and (3) strengthening efforts to implement process changes that reduce the risk of future errors and improve patient care. The fundamental purpose of reporting systems for medical errors is to learn how to improve the health care delivery process to prevent these errors. Reporting of medical errors must become culturally accepted throughout health care. A major investment of resources will be required in the health care system to apply the lessons derived from the reporting of medical errors. Marshaling those resources is an urgent issue for the governing boards of health care institutions, health care administrators, health professionals, purchasers of health care (including federal and state governments), third party payers, public policy makers, credentialing organizations, the legal profession, and consumers.