EVERYONE HAS expressed horror at reports that medical errors kill as many as 98,000 people a year. Doctors and researchers alike call for changes in a "culture of medicine" that sees mistakes as sinful and unthinkable, therefore undiscussable. But changing a culture is a tough proposition, even with universal agreement as to its urgency. What changes can make a difference to these frightening error rates?

President Clinton quickly embraced the major recommendations put forth in the Institute of Medicine study of errors. He called on government-funded facilities and health plans that insure federal workers to adopt procedures for reporting errors and tracking "adverse events," whether or not they result in serious injury. The Veterans Administration, which adopted such policies in 1997, found errors associated with as many as 700 patient deaths between June 1997 and December 1998. But noting errors is only a first step toward preventing them, and here the VA's experience offers another, more striking lesson.

One broad "cultural" factor often cited as inhibiting hospitals from such public admission and scrutiny of error is fear of malpractice lawsuits. But the Annals of Internal Medicine this month published a study showing that in one VA hospital, the Veterans Affairs Medical Center in Lexington, Ky., a policy of prompt and full disclosure of all errors to patients--including errors patients would have remained unaware of--actually saved the hospital money over two years by drastically cutting litigation costs. Not that the hospital made no cash settlements; it offered compensation to patients and their families and even helped them file claims. But relationships were less adversarial and settlements considerably lower, bringing savings on balance.

There's no telling whether this would work across the board. In VA hospitals, unlike others, doctors are shielded from personal malpractice liability. But just as hospitals may need to move away from the myth that doctors never err, they should explore the possibility that open admission of mistakes puts them in less conflict with patients, not more.