A first step toward understanding patient safety

Kim, Kyoung Ok

The aviation industry recognized the importance of data and introduced an internal confidential error reporting system in 1982 [19] . This confidential reporting system guarantees immunity from prosecution and encourages individuals to report errors without fear of punishment, enabling frank and accurate discussions about errors and system weaknesses. This benefit is equally applicable to the practice of clinical medicine and is KOREAN J ANESTHESIOL Kyoung Ok Kim essential for patient safety [19] . Medical error cases are often so complex and debatable that honest and detailed reporting is key to identifying the reasons for the accident. An error reporting system is currently being used in the USA, UK, Denmark, and several other countries. The Danish Parliament passed the Act on Patient Safety in 2003, following a study reporting that 9% of patients admitted to a Danish hospital were involved in an adverse event [20] . This is the first legislation in the world that has sought to improve patient safety by ensuring that all adverse events are reported and that the National Board of Health will disseminate the results nationally [21] . The US Senate passed the Patient Safety and Quality Improvement Act (PSQIA) in 2005 [22] . The PSQIA introduced a voluntary reporting system to facilitate assessment of data to improve patient safety and healthcare quality. The UK's National Patient Safety Agency created the National Reporting and Learning System in 2003, which is a nationwide voluntary event-reporting system for patient safety [23] . Japanese healthcare workers are also familiar with event-reporting systems because all Japanese hospitals established an in-house, legally bound event-reporting system in 2002 [24] . The Patient Safety Act, which includes a voluntary reporting system, will go into effect in July 2016 in Korea [25] .