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Patient safety incident reporting continues to improve

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 October 2013 and 30 April 2014. 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 12.8% in the number of incidents reported compared to the same six month period in the previous year. This increase shows the NHS is continuing to be more open and transparent around the reporting of patient safety incidents.

The reporting of incidents to a national central system helps protect patients from avoidable harm by increasing opportunities to learn from mistakes and where things go wrong. The NHS uses these reports 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 the NHS’ work to rapidly alert the healthcare system to risks and to provide guidance on preventing potential incidents that may lead to avoidable harm or death.

Incident reporting is also important at a local level as it supports clinicians to learn about why patient safety incidents happen within their own service and organisation, and what they can do to keep their patients safe from avoidable harm.

Data published today on the NRLS website shows that:

  • In the six months from October 2013 to March 2014, 778,460 incidents in England were reported to the system – 12.8% more than in the same period in the previous year.
  • Of those reported, 69.1% were reported as causing no harm. 24.8% were reported as causing low harm, meaning the patient required only increased observation or minor treatment as a result of the incident.
  • 5.5% 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 at 0.24%, down from 0.26% reported for the same period in the previous year.
  • The top four most commonly reported types of incident have remained the same: patient accidents (20.9%), implementation of care and ongoing monitoring/review incidents (11.4%), treatment/procedure incidents (11.3%), 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.

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3 comments

  1. Jacqueline Rigby says:

    Has NHS England a matrix of examples of the different levels of harm for different care examples to support staff in determining the level of harm.
    I am aware of the NPSA definitions, but would be helpful to have further clarification to check out our understanding

  2. Kelvin Rowland-Jones says:

    I note from the briefing above that “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.”

    I cannot see any data on the incidents reported by primary care organisations – is this available?
    My particular interest is in dispensing incidents reported by community pharmacies and dispensing doctors. In the 18 months of NHS England I have not seen any data or reports about these incidents. As an AT contract manager I therefore have not been able undertake any meaningful work in this area with my 600 plus contractors. Will there be any information on this important subject in the near future?

    Regards

    Kelvin

  3. Maria Dineen says:

    This is good news. However, I know that many of our adverse event investigations remain suboptimal for a whole host of reasons and ‘recommendations’ for improvement remain ill focused and ill thought out inspite of best effort and intention. A significant contriutory factor is that many NHS staff do not understand how to deliver a good investigation and because the NPSA’s tool kit (and other valuable technicques and tools) are not being used to optimal effect because the ‘NPSA’ report template is acting as a ‘straight jacket’ to investigation practice. NHS Staff need to be encouraged to use a flexible range of approaches to deliver best learning from adverse events and not be left feeling that they can ‘only’ do a timeline and the fishbone! – I see this far too often and it is counter productive to patient safety – it really is. Staff put a lot of energy in trying to learn from incidents – they will be more successful if ‘the centre’ says it’s OK to use any and all of the range of techniques out there, providing the core principles of good investigation practcie (+/- systems and HF factors analysis where appropriate) are applied.
    It really would make a huge difference, as would scrapping the now unhelpful NPSA ‘report writing template’. A flexible template yes – absolutely where the author can adjust it to meet the needs of the investigation and thus the ‘report in hand’ but not something that is interpreted and promoted as a ‘you must use this’ . It generates ‘box filling’ – that I am sure was not the intent when it was designed.