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New milestone reached in NHS patient safety – Mike Durkin

Mike Durkin, NHS England’s National Director for Patient Safety, marks the tenth anniversary of the National Reporting and Learning System

Sunday November 24 marks a significant milestone for patient safety in the NHS, as the National Reporting and Learning System (NRLS) reaches the tenth anniversary of the first incident reported.

Millions of incidents have since been reported through NRLS, with latest figures showing 1.4 million each year, clearly demonstrating the progress being made to ensure we can learn from errors and appropriate steps can be taken to keep our hospitals safe.

The NRLS was set up in 2003 as the first tangible step towards the culture change called for by Sir Liam Donaldson in his seminal paper on patient safety, An Organisation with a Memory. In that report, Sir Liam called for a revolution on the way healthcare views patient safety incidents. Rather than hiding and punishing error, healthcare professionals should be talking about them, learning from them, and being open with the patients and families affected by them.

The NRLS is the first attempt in the world to aggregate incident data at a national level, and while I recognise the process isn’t perfect due to the complexity of how incidents are reported, it has put together the best evidence yet that the NHS has made real progress towards the learning culture Sir Liam called for over a decade ago.

The fact that we are now receiving 1.4 million incidents a year can be wrongly perceived that the NHS is becoming less safe, which is a wholly incorrect assumption to make.

What it does show is that doctors, nurses and other healthcare workers are now, more than ever before, reporting mistakes and trying to learn from them for the benefit of their patients.

As Don Berwick made clear in his recent report, we need to openly and honestly report safety incidents so we can fully understand and manage the risks inherent in all healthcare systems.

The data we gather through NRLS enables us to identify emerging risks and patterns in patient safety incidents at a national level, which may not be obvious at a local level. It also provides a rich source of data for patient safety research teams at universities and in hospitals, galvanising innovation in safety care. We are also able to share the data with key national partners and regulators such as the Care Quality Commission (CQC) and the Medicines and Healthcare Products Regulatory Agency (MHRA).

Looking ahead to the future, we are in the process of developing a new incident reporting system based on NRLS which will better facilitate learning and improvement in the NHS as we strive to take all aspects of patient safety to the next level.

We will shortly begin consulting with a number of key partners, including patient groups, to ensure the new reporting system is designed to meet the needs of those who matter, as the NHS continues to be a world leader in patient safety reporting and learning.

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4 comments

  1. dipak says:

    Some of the respondents are missing the point. As a registered nurse and a registered ergonomics and human factors practioner. CHIRP The aviation reporting system which NRlS is based on is confidential. CHIRP stands for “confidential” human factors incident reporting programme. When will people learn! Its not about naming and shaming people.

  2. Mohammed Sheikh says:

    It is indeed encouraging to see the rise in incident reporting but as a patient safety practioner, my feeling is that a very large proportion of these incidents are reported by the acute (and community services) providers. Although most NHS patient contacts are made in the primary care, yet the number of incident reporting in primary care remains patchy. Bravo! our primary care colleagues – it would be great to see how you see patient safety develop to the next stage!!

  3. Jenny Hughes says:

    Until you collect names/team and at which Trust the error/s occurred you will continue to close your eyes to badly-performing and dangerous clinicians, teams and Trusts. You can’t use protecting their confidentiality as an excuse: patient safety, protecting users and being able to notice excess morbidity (why don’t you collect this, at present = only excess deaths, why?) and patterns of errors trumps NHS staff’s right to privacy. No other trade or job protects their bad workers the way the NHS/medicine does – except banking maybe? Get real and put patient safety at top.

    Dr Umesh Prabhu (below) says 200 patients a day are harmed but this is just the tip of the iceberg: these are the ones who report and whose errors are accepted as fact (by doctors and Trusts rather then denied and therefore not ever listed) and counted, it is way below the actual numbers and going by people I know and my own history less than 10% ever bother reporting or complaining.

  4. Dr Umesh Prabhu says:

    Dear Mike

    Good to see NRLS celebrating 10th year and success of NPSA and patient safety so far and NHS must be proud of huge progress we have made. But, please do not underestimate the challenge regarding patient safety in many Trusts and CCGs. Sadly good practice is patchy in our NHS. Recently met nearly 300 BME consultants and GPs who told me that they are scared and frightened to raise concerns about patient safety because of poor culture, bullying, victimisation and poor leaders.

    This has to be addressed and we got to make sure that Board is held responsible for poor culture, poor leadership. If not patients will continue to be harmed.

    I am very proud of NHS and does a great job but sadly 200 patients a day are seriously harmed and we got to do something urgently so that we all can be proud of our NHS