Development of the Patient Safety Incident Management System (DPSIMS)


The National Reporting and Learning System (NRLS) is a database of patient safety incident reports submitted by organisations across the NHS, specifically for purposes of learning. The majority of reports come from trusts, which regularly upload incident reports from their local systems to the NRLS, where they are interrogated by national patient safety experts to spot trends, specific incidents of concern, or emerging risks to patient safety. This triggers action to help address the identified issues/risks through the provision of advice and guidance, e.g. a Patient Safety Alert.

Reports are also submitted by other providers, such a General Practitioners (GPs) and community pharmacies, which is currently less common, though there is work underway to help support these non-acute sectors of healthcare to report more.

However, the NRLS is now almost 10 years old and due for an upgrade, and so the DPSIMS project aims to identify and assess the options for a successor system that will build upon the success of NRLS, but potentially expand its functions to create a Patient Safety Incident Management System (PSIMS) that will better meet the needs of patients and clinicians within current NHS delivery models, with the intention of delivering a new system in 2018.

Latest News

Following our stakeholder engagement work, 13 high-level options were developed for the delivery of a new PSIMS. These options have been assessed by a panel of senior stakeholders to identify a shortlist for inclusion in the Strategic Outline Case (first-stage business case) for DPSIMS. The stakeholder update below provides details of this process and an overview of the options shortlisted.

The key findings from a series of DPSIMS Site Visits are available below. We would like to thank all sites who volunteered, and extend enormous gratitude to the host organisations for their time and expertise in supporting this work.

An update from December 2014 is available below.

The name of this project has been recently changed from “NRLS Development” to better reflect the future state of the system, and differentiate the existing arrangements from those we hope to implement through this work. The content of the project remains unchanged.

Purpose and Vision

The purpose of the DPSIMS project is, over three years, to identify the most appropriate option for a successor to the NRLS, develop a business case for this option, and procure it for delivery to the NHS.

To do this, it will engage with a variety of stakeholders to assess needs, and to develop a rigorous assessment of the options in terms of technical feasibility, benefits, risks, economic impact, and strategic alignment with the work of the Patient Safety Domain in NHS England and also the other organisations in the healthcare system who have specific responsibilities in relation to safety.

The vision is to identify a solution with reduces the risks associated with duplication, a lack of standardisation and the gap between current NRLS capability and the needs of the NHS, improves transparency and patient involvement, and that generates better learning that supports more improvement across all sectors of NHS-funded care in England.

Our intention

Our hope for this work is that it will provide a system that meets both local and national needs in terms of accessibility to both staff and patients/carers, integration and interoperability with appropriate other systems, and with the proper balance of confidentiality and transparency, supporting a just, open and honest NHS culture.

We want to support good patient safety culture in the NHS, and develop a system that enables all roles and responsibilities related to national and local investigation of patient safety incidents, including those of providers, commissioners and regulators, and the role of the centre in identifying high-level trends and patterns not apparent at a local level. Likewise, we want to support patients to be involved in learning opportunities and solutions, and provide them with information to help make their future healthcare choices.

It is imperative that we find a technically robust option that represents security, value for money, and fitness for purpose in the medium and longer terms.

Finally, it is our intention to work with NHS colleagues and patients alike throughout the process, to ensure that our chosen solution matches their needs as closely as possible.

Find out more

For further information, please email: