In order to better understand the opinions and experiences of hospital leaders with mandatory state reporting systems, this survey study collected data from a random sampling of chief executive and chief operating officers. Results demonstrated substantial concern about the impact of these systems on internal reporting systems and the potential for encouraging litigation while limiting patient safety efforts. Vignettes illustrating hypothetical errors and the types of errors most and least likely to be reported are included. The authors discuss challenges in balancing the importance of reporting systems with the legal and regulatory factors that likely foster the findings in this study.