Shadowfax: “What is needed is a safe method for docs to routinely report the ‘near misses,’ like mine, where they can be reviewed and discussed and the contributing factors identified. Where the verdict won’t be ‘Dr SF is a bad doctor,’ but ‘factors X and Y contributed to Dr SF’s error which then caused Z.’ Where there is protection for health care providers who self-report to encourage the capture of as many cases as possible, to better extract the data and deduce the ultimate causes.

I don’t see this happening in my lifetime. The tort system is too entrenched and consumes too much of the oxygen in the room, and represents a prohibitive barrier to physician disclosures.”