Anonymous reporting has an important role

If the current rate of iatrogenic harm in health care is to be reduced there is widespread agreement that we need to identify how and why adverse events occur, and, in particular, how system defects may contribute to their occurrence. This view underlies reports such as An Organisation with a Memory1 in the United Kingdom and similar reports in other countries2 and has led to political commitment to national monitoring systems. As Britain's new National Patient Safety Agency, currently being established, starts to ponder the issue, what are the elements of a successful reporting and monitoring system?

In spite of this recent recognition of the need for monitoring, disagreement remains about the attributes of the ideal reporting system. There are at least two distinct objectives. One is to identify practitioners or units whose performance is substandard and processes, infrastructure, or equipment that are manifestly inadequate or dangerous and to deal with these particular problems at a local level. To do this …