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Patient safety incident reporting continues to improve

NHS England has today (23 September 2015) published a six-monthly data report on patient safety incidents reported to the National Reporting and Learning System (NRLS) between 1 October 2014 and 31 March 2015.

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 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 data published today sees an increase of 6.0% in the number of incidents reported compared to the same six month period in the previous year.

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 2014 to March 2015, 825,416 incidents in England were reported to the system, 6.0% more than in the same period in the previous year.
  • Of those reported, 71.2% were reported as causing no harm. 23.9% were reported as causing low harm, meaning the patient required only increased observation or minor treatment as a result of the incident.
  • 4.3% 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 0.22%, down from 0.24% reported for the same period in the previous year.
  • The top four most commonly reported types of incident have remained the same: patient accidents (19.2%), implementation of care and ongoing monitoring/review incidents (13.2%), treatment/procedure incidents (10.6%), and medication incidents (10.2%).

Awareness around the importance of incident reporting is continuing to be driven via initiatives such as the Sign up to Safety campaign and is a priority area for the 15 patient safety collaboratives that have been launched to further improve patient safety across England.

NHS England is also working to increase reporting from areas of healthcare that have previously had low levels of reporting to the NRLS, such as general practice. As part of this work, in February 2014 a new e-form was launched, specifically designed to make it quick and easy for general practice staff to report patient safety incidents to the NRLS.

Understanding NRLS data:

  • The National Reporting and Learning System (NRLS) is a voluntary scheme for reporting patient safety incidents, and therefore it does not provide the definitive number of patient safety incidents occurring in the NHS, only those that have been reported via NRLS.
  • When a patient safety incident happens, NHS staff can make confidential online reports via their local reporting systems. All staff are encouraged to report all incidents, whether they result in harm to patients or not.
  • Year on year the number of incidents reported increases. This is actually a good thing, and that’s why the NHS Outcomes Framework looks to see an increase in incidents reported to the NRLS. CQC uses low reporting rates of incidents as a concern in their Intelligent Monitoring System
  • A ‘low’ reporting rate from an organisation should not be interpreted as a ‘safe’ organisation, and may represent under-reporting. Subsequently, a ‘high’ reporting rate should not be interpreted as an ‘unsafe’ organisation, and may actually represent a culture of greater openness.
  • Experience in other industries has shown that as an organisation’s reporting culture matures, staff become more likely to report incidents. Therefore, an increase in incident reporting should not be taken as an indication of worsening patient safety, but rather as an increasing level of awareness of safety issues amongst healthcare professionals and a more open and transparent culture across the organisation.
  • NHS trusts are organisations constantly in change.  They close, merge, add and take away services, each of these services with very different risk profiles.  Comparing a trust to another trust to see which is safer won’t work, and even looking at a single trust across a number of years you are actually comparing very different organisations.
  • There are a range of other indicators and methods that can be used to demonstrate patient safety and quality of care such as never events data, the NHS Safety Thermometer, and performance against patient safety related CQUINs.

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One comment

  1. Michael Ritson says:

    WHY DO THE NRLS FIGURES NOT INCLUDE NHS LITIGATION CASES?
    (AND HAS NOT DONE SO FOR MANY YEARS!).
    I wrote to Tim Kelsey (and others) on this matter at least two years ago and received no response (not even an acknowledgement of receipt).
    Best regards
    Mike R
    Patient Rep.