Joint Commission weighs in on mandatory reporting of medical errors

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, recommends that any mandatory reporting of medical errors be structured to accommodate the systems already in place to deal with errors.

In a recent statement, the Joint Commission says it "supports the creation of an effective medical/health care error reporting system, whether mandatory or voluntary," but only if it has these characteristics:

1. Events to be reported to the system must be well-defined and, if the system is mandatory, limited to serious adverse events.

2. Reports of serious adverse events must include the findings of the root-cause analyses of those events.

3. All information reported to the system must be protected legally from disclosure, including by subpoena, discovery, introduction of evidence, testimony, or any other form of disclosure in connection with a civil or administrative proceeding under federal or state law or the Freedom of Information Act.

4. The Joint Commission and other health care oversight bodies with a legitimate "need to know" must have full and timely access to the data in the reporting system, on a health care organization-specific basis. That includes data about the adverse events, their root-cause analyses, and the actions taken to reduce future risk. Disclosure of that information to accrediting bodies or other quality oversight bodies must not result in waiver of any protection against disclosure of the information provided by state or federal law.

5. The Joint Commission must play a central role in the evaluation of root-cause analyses for its accredited organizations and in the dissemination of information to the health care field that facilitates learning about and implementing actions to improve patient safety.