In the seven years since the Institute of Medicine's report "To Err is Human: Building a Safer Health System" much has been said about the types of errors prevalent in healthcare and ways of reducing these errors.

While some progress has been made, one aspect of medical errors has garnered little attention. Specifically, there is a disincentive to report errors.

If we lived in a world in which physicians were simply servants of their patients, the only question going forward would be how to reduce medical errors. But in the real world we must ask in addition how to decouple error reporting from financial and professional risk to healthcare providers.

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Ask any surgeon and they'll tell you that complications happen - and they're usually not a problem if you know about them.

It's not unheard of, though, that medical errors are hidden are from colleagues and patients because of fear of liability, reprimand or other damage.

This is an especially serious problem in the hierarchical environment of residency programs, where residents care for a patient under an attending's priveleges, but their training is incomplete (for a humorous, yet telling blog on this, see Interns Lie).

Anyone who has sat through an M&M conference gone sour can appreciate the resident's dilemma: report an error and risk public humiliation before tens or hundreds of their colleagues. Dismissal from a residency program is also a real, although less frequent, concern.

Supervision of residents has increased over the last decade, with the implementation of new rules on when an attending needs to be in house, but these rules were instituted by insurance concerns, not initiated by physicians.

M&M conferences are important - perhaps among the most important - learning venues for medical professionals and should be preserved. Nor am I suggesting that residents be exempted from responsibility in the care they provide.

But, we as physician must find a way to decouple education and training from the incentive to report (or not report) one's own errors.

Two steps are needed to start. First, we need to get an appreciation of the magnitude of the problem. I suspect an informal survey would find that a large number of young physicians have seen a colleague cover up an error - but there is no data on this issue. If the study finds a substantial number of problems, then physicians - not insurers, not hospital administrators - but physicians must develop an approach to dealing with it.

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