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NHS England today welcomed the publication of six-monthly data on patient safety incidents reported to the National Reporting and Learning System (NRLS) between 1 April and 30 September 2013. The data shows the NHS is continuing to get better at recognising and reporting patient safety incidents.
Acute hospitals, mental health services, community trusts, ambulance services and primary care organisations report incidents to the NRLS where any patient could have been harmed or has suffered any level of harm. The data published today sees an increase of 8.9% in the number of incidents reported compared to the same period in the previous year, as the NHS continues to be more open and transparent around patient safety incident reporting.
This increase in reporting further helps protect patients from avoidable harm by increasing opportunities to learn from where things do go wrong, enabling NHS England to identify and take action to prevent emerging patterns of incidents on a national level via patient safety alerts. These alerts are a crucial part of NHS England’s work to rapidly alert the healthcare system to risks and to provide guidance on preventing potential incidents identified through the NRLS that may lead to harm or death.
On a local level, incident reporting enables clinicians to learn from their own and others’ services about why patient safety incidents happen, so that they can act to prevent their own patients being placed at similar risks.
Data published today on the NRLS website shows that:
- In the six months from April 2013 to September 2013, 725,314 incidents in England were reported to the system – 8.9% more than in the same period in the previous year.
- Of those reported, 67.7% were reported as causing no harm. 25.7% were reported as causing low harm, meaning the patient required only increased observation or minor treatment as a result of the incident.
- 6.0% were recorded as causing moderate harm, meaning that the patient suffered significant but not permanent harm, requiring increased treatment.
- The proportion of incidents resulting in severe harm or death remains less than 1% of all incidents reported, with the percentage resulting in death unchanged from the same period in the previous year, at 0.27%.
- The top four most commonly reported types of incident have remained the same: patient accidents (21.4%), implementation of care and ongoing monitoring/review incidents (11.5%), treatment/procedure incidents (11.0%), and medication incidents (10.7%).
Clinicians in NHS England review all incidents resulting in severe harm and death, and have observed that the accuracy in coding of these incidents is improving, further demonstrating increased engagement with the importance of reporting and learning from patient safety incidents.
Dr Mike Durkin, NHS England Director of Patient Safety, said:
“It is hugely encouraging to see more and more incidents being reported as this demonstrates that not only doctors, nurses, midwives but all NHS staff feel increasingly comfortable with speaking openly about mistakes and learning from error. Incident reporting is our best indicator of whether an organisation’s culture is becoming more open and transparent. The incidents reported to the NRLS are key to patient safety as they enable us to identify problems nationally and take action to alert the NHS to emerging risks.
“This summer we will be setting up local patient safety collaboratives, learning labs that will help patients and all staff who work in healthcare to share their learning and problem solve together across a wider team in each area. As Professor Don Berwick made clear in his report last year, we need to support the NHS to become a system devoted to continual learning and improvement.”