Creating problems as part of the "solution": the JCAHO Sentinel Event Policy, legal issues, and patient safety.

The recently reported number of patient deaths attributable to medical errors is staggering. In response to this crisis, the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") proposed its Sentinel Event Policy. The policy mandates self-reporting by hospitals accredited by the JCAHO. This Article argues that the JCAHO's policy shows an inattention to the legal realities of discovery and absence of immunity. Until the JCAHO addresses these issues, self-reporting will have limited success. This Article suggests that to promote patient safety, self-regulatory reports should go to a neutral, nonsanctioning third party, an approach adopted from aviation's highly successful reporting system.