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The NHS Commissioning Board has today released the National Reporting and Learning System (NRLS) Organisation Patient Safety Reports. These show progress in the reporting of patient safety incidents from April to September 2012.
The figures are collected to help clinicians to identify where and how incidents occur in order to prevent them in the future. The NHS Commissioning Board has put initiatives in place which will also use the learning from these reports to reduce harm to patients.
Mike Durkin, Director of Patient Safety from the NHS Commissioning Board, said:
“We have put a number of initiatives in place to significantly reduce incidents of patient harm and it will continue to develop a system that will become an exemplar of good practice in the reporting of harm. This must continue to be the foundation of supporting a culture of openness and transparency in the way we support our patients. It must matter to everyone in healthcare that we do not walk past when we see a harmful, or potentially harmful, event.
“Firstly, a three year strategy for nursing, midwifery and care staff will contribute to high quality, compassionate and excellent health and wellbeing outcomes for patients.
“Secondly, Professor Donald Berwick is being brought to the NHS to chair a National Advisory Group on the Safety of Patients in England. The group includes world-leading experts in all aspects of the culture and processes of minimising patient harm and will advise the NHS in England on how to prevent patients being harmed while receiving healthcare.
“Thirdly, Professor Sir Bruce Keogh will lead an investigation into fourteen hospitals that are persistent outliers on mortality indicators.
“The NHS sees over 1m people every 36 hours, the overwhelming majority of which experience no harm and patient satisfaction remains high.”
Experience in other industries has shown that as an organisation’s reporting culture matures, staff become more likely to report incidents.
An increase in incident reporting should not necessarily be taken as an indication of worsening of patient safety, it may indicate an increasing level of awareness of safety issues amongst healthcare professionals and a more open and transparent culture across the organisation.
The proportion of incidents reported as resulting in severe harm or death remains less than one per cent of patient safety incidents. However there was an increase of 0.6 per cent in the reporting of these incidents when compared to April to September 2011.
While the biggest increase in reporting of severe harm or death was in mental health – an increase of 0.38 per cent – the reason was a change in the reporting arrangements. The figures now include all apparent and actual mental health suicides where the patient has an open episode of care either as an inpatient or in the community.
The incidents reported during April and September 2012 fit into four categories:
- 67.2 per cent were reported as resulting in no harm to the patient
- 25.5 per cent were reported as resulting in low harm
- 6.4 per cent were reported as resulting in moderate harm
- 0.9 per cent were reported as resulting in severe harm or death.
Patient accidents continue to be the most frequently occurring type of incident (24.0 per cent) reported to the NRLS. However, there has been a steady decrease in both the number and percentage of patient accidents reported as occurring over the last two years. This was ranked as the fifth most commonly reported type of incident (8.0 per cent) occurring during October 2010 to March 2011. It is now the second most common type of incident representing 10.9 per cent of incidents reported as occurring during April to September 2012.
In contrast, incidents categorised as ‘implementation of care and ongoing monitoring/review’ have continued to increase consistently over the last two years.
This was the second most commonly cited category of incident report, representing 10.9 per cent of the total from April to September 2012. From October to March 2011 it was fifth (8.0 per cent).
The types of organisation that report most frequently have not changed in the last six months (April to September 2012)- large acute trusts 24.9 per cent; acute teaching trusts 23.2 per cent; medium acute trusts 18.4 per cent; and mental health organisations 17.4 per cent.
One hundred and five organisations reported ten or fewer patient safety incidents as occurring over the six month period April to September 2012. All one hundred and five have no inpatient provision. This is likely to be a reflection of the reorganisation of primary care trusts that took place in early 2011 when PCTs became commissioning only organisations.
The number of incidents reported may well continue to rise in the coming months as organisations develop their systems and the culture of reporting becomes more embedded.
Increasing the reporting of incidents among elderly and mental health patients remains a priority for the NHS as well as increasing the reporting of incidents in primary care.
All data is available on the NRLS website.