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Invited Critique |

Development of an Online Morbidity, Mortality, and Near-Miss Reporting System to Identify Patterns of Adverse Events in Surgical Patients—Invited Critique

Martin A. Makary, MD, MPH
Arch Surg. 2009;144(4):311. doi:10.1001/archsurg.2009.6.
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Every day we apply years of rigorous training to work in an extremely high-risk and litigious environment. Yet, in no other industry are consequential errors dealt with in such a haphazard, reactionary, and secluded manner.

Regrettably, research in patient safety has lagged behind surgeons' demand for it. That is, the area of safety has been plagued by a paucity of scholarship and data. In light of this deficit, Bilimoria et al have advanced the field by describing a standardized method to capture events and classify them in a systematic way. Commendably, they promote the science of safety by testing a defined intervention. In short, Bilimoria et al show how we can learn from mistakes in a more organized and comprehensive way. Most importantly, they uphold the key pillars of patient safety: evaluate systems, standardize processes, and learn from mistakes.

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