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subsequently used against them. Thus, the prominence of litigation can be a substantial deterrent to the development and maintenance of the reporting systems discussed in this report.

Chapter 5 lays out a strategy to encourage greater recognition and analysis of errors and improvements in patient safety through a mandatory reporting system for errors that result in serious harm, and voluntary participation in error reporting systems that focus on "near misses" or errors resulting in lesser harm. The issue of whether data submitted to reporting systems should be protected from disclosure, particularly in litigation, arose early in the committee discussions. Members of the committee had different views. Some believed all information should be protected because access to the information by outsiders created concerns with potential litigation and interfered with disclosure of errors and taking actions to improve safety. Others believed that information should be disclosed because the public has a right to know. Liability is part of the system of accountability and serves a legitimate role in holding people responsible for their actions.

The recommendations contained in Chapter 5 and in this chapter reflect the committee's recognition of the legitimacy of the alternative views. The committee believes that errors that are identified through a mandatory reporting system and are part of a public system of accountability should not be protected from discovery. Other events that are reported inside health care organizations or to voluntary systems should be protected because they often focus on lesser injuries or non-injurious events that have the potential to cause serious harm to patients, but have not produced a serious adverse event that requires reporting to the mandatory system. Protecting such information encourages disclosure of problems and a proactive approach to correcting problems before serious harm occurs.

Although information about serious injuries and deaths due to errors should not be protected from discovery, it is important that information released to the public is accurate. As described in Chapter 5, mandatory reporting systems receive reports on adverse events, which are then investigated to determine whether an error occurred. The mere filing of a report should not, by itself, trigger release of information. Rather, information should be released after an investigation has been completed so the information that is released is accurate. This chapter focuses primarily on protecting information reported to voluntary systems, although aspects may also apply to protecting data submitted to mandatory systems until the information is ready for public release.

The committee believes that a different approach to promoting the col-

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