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.