State adverse health incident reporting systems in the United States

Abstract

In the United States, the multiple overlapping adverse event reporting systems for patient safety reflect the country’s fragmented, inefficient, and inequitable health care finance and delivery system. This Chapter provides a brief description of the United States' health care environment and its impact on the frequency of adverse events. It includes an overview and the progress in state-by-state adverse event reporting systems and a discussion of the role of the Joint Commission's "Speak Up" initiative. The Author concludes that, in spite of the system's gaps and failings, the efforts of many physicians, health care institutions, regulatory bodies, and other stakeholders deserve both recognition for their roles in improving its safety and substantially more governmental and budgetary support going forward.