Adverse event reporting systems and safer healthcare.

At the heart of improvement and safety in healthcare is the now-familiar tenet that was espoused decades ago by Demming and paraphrased by Berwick. Need we repeat it again? Every defect should lead to improvement processes that make care safer. It is time to deliver on the promise of reporting systems in patient safety. While it is clear that event-reporting systems are now central elements in effective patient safety systems, their growth and implementation have been slow, and their effective use for implementing strategies for safer care has been even slower. In the decade since the report of the Institute of Medicine (IOM) to Err is Human released in 1999, and an Organization with a Memory published in 2000, consensus has grown that learning from patient safety events is an essential part of creating safer healthcare systems—at both national and local levels.