Mandatory Reporting of Medical Errors: Crafting Policy and Integrating It Into Practice

Estimations of preventable adverse events as a result of medical errors range from at least 44,000 to as many as 98,000 American deaths annually. Further, according to the National Practitioner Data Bank's 2006 Annual Report, 12.2% of medical malpractice payments against nurse practitioners (NPs) were a consequence of medication-related problems. Implementing mandatory reporting of all medical errors and “near misses” (errors that produce minimal or no patient harm) may be one policy approach to this problem. In 1995, Kingdon began to consider how an issue is placed on a political agenda and eventually translated into a public policy. As Kingdon noted, under certain circumstances, a window of opportunity is created, and given current changes in both the executive and legislative branches of the federal government, there may now be the perfect opportunity to address medical errors and near misses. This serious public health issue is analyzed using Kingdon's model, and policy approaches aimed at diminishing medical errors are considered.