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Introducing our new system for patient safety learning

In Spring 2021, a new national Patient Safety Incident Management System (PSIMS) will enter its public beta stage. The new system will be phased in to replace the current National Reporting and Learning System (NRLS). Its aim is to maximise the NHS’s ability to learn from when things go wrong. In this, the first in a series of blogs from Lucie Mussett, PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer.

Recording safety events, whether they result in harm or not, provides vital insight into what can go wrong in healthcare and how these events happen. This is why over 16 years ago, the NHS launched the National Reporting and Learning System (NRLS); a world-first as a single national system receiving incident reports from across a nation’s healthcare providers, allowing for patterns, trends, and new risks to the safety of patients be identified at a national level.

Thanks to the dedication of many thousands of healthcare staff who’ve shared information when things have gone wrong, the NRLS has grown to a database of over 20 million incident reports, providing a rich vein of patient safety data. It has formed the backbone of the NHS national patient safety team’s ability to rapidly identify and respond to national-level safety risks, leading to hundreds of interventions to support the NHS to keep patients safe, and provides vital insight for long-term patient safety improvement programmes.

Sixteen years on, despite the NRLS’s undoubted success, today’s NHS needs a new and improved system that better represents changes to the way care is delivered in the modern healthcare landscape, and takes full advantage of advances in technology so we can maximise opportunities for learning.

Responding to the challenge, we’ve undertaken a programme of extensive development, working with patients and staff from all health and care settings, to create the new Patient Safety Incident Management System (PSIMS). The system will begin its public beta phase during Spring 2021, meaning some providers (those with compatible local reporting systems) will be able to start uploading the safety events their staff report onto PSIMS, instead of the NRLS. And staff working in smaller organisations without a local risk management system, such as in primary care, will be able to start recording safety events directly onto PSIMS using a web account and new and improved online forms.

Once fully functional, PSIMS will introduce improved capabilities for the analysis of patient safety events occurring across healthcare. For example, it will:

  • make it easier for staff across all healthcare settings to record safety events, with automated uploads from local systems to save time and effort, and introduce new tools for non-hospital care where reporting levels have historically been lower
  • collect information that is better suited to learning for improvement than what is currently gathered by existing systems
  • make data on safety events easier to access, to support local and specialty-specific improvement work
  • utilise new technology to support higher quality and more timely data, machine learning, and provide better feedback for staff and organisations.

The public beta is a final phase of piloting, throughout which new functionality will be added to PSIMS as we continue to meet any newly identified user needs. We are also working with suppliers of local risk management systems who are rolling out a programme of upgrades to move organisations onto products that will be compatible and compliant with PSIMS, supporting two-way communication between local and national systems, and allowing automated data sharing.

Over the next few years, once they are able to, all organisations will switch to reporting to PSIMS and the NRLS will cease to accept new reports. We will also embark on a programme to encourage further reporting from healthcare settings that have traditionally been less likely to report to a national system. This will ensure PSIMS is truly representative of the NHS as a whole and can support improvement wherever care is delivered.

I’ll be posting further blogs over the coming weeks, where I’ll go into more detail of the benefits of PSIMS, and some of the other changes we’ll be introducing to support safety improvement, and change the way we think about recording safety events.

In the meantime, you can find out more about the new system and how it is being introduced on our PSIMS webpage, or follow me for updates on Twitter via @LucieNHSsafety.

Lucie Mussett

Lucie leads the project to develop the new Patient Safety Incident Management System, and acts as the Product Owner on the digital agile team. She has a background in health policy, and has been part of the national patient safety team since 2013.