1.1 Transition of recording systems

NHS England previously published official statistics using National Reporting Learning Service (NRLS) patient safety incident data: the National Patient Safety Incident Reports (NaPSIR), and Organisation Patient Safety Incident Reports (OPSIR). In addition, we published monthly summary data which complemented our official statistics data reports.

However, due to its aging infrastructure, NRLS was withdrawn on 30th June 2024, and replaced by the Learn from Patient Safety Events (LFPSE) service, which has been operating since July 2021. You can read more about the new service here. Transition of all secondary care providers from the old system to the new was completed in 2024. This is the first experimental publication of statistics relating to LFPSE, and as a result there are some key differences between NRLS and LFPSE which should be considered when interpreting this data. The change contributes significantly to the alteration of data output in our new official publications.

NRLS submissions required manual extract and upload, whereas LFPSE submissions occur in real time, including any updates made to records after their initial submission as the provider works towards a full and accurate picture of the event over time.

NRLS used older definitions, and was primarily used by secondary care providers, due to its reliance on secondary-use data inputted to Local Risk Management System (LRMS) software, which varies from provider to provider.

LFPSE offers an interface for providers without LRMS software to use the same tools, making it more accessible to primary care and other settings, as well as supporting submissions from private healthcare providers.

This means that NRLS and LFPSE data are not comparable, and we expect to see differences in recording patterns and usage through the transition period and beyond. This is also true for the taxonomies (question set, and answer options), as the taxonomies used within LFPSE have been updated to capture more mechanistic details of how things go wrong, to allow us to develop targeted interventions to improve safety where they will be most effective.

Although connection to the LFPSE service is now a contractual obligation, LFPSE operates as NRLS did in terms of being a largely voluntary system. Decisions on which events to record are not mandatory, except where recording a death or instance of severe harm fulfills mandatory notification requirements. Providers are encouraged to record as much as they can, and particularly what is thought useful for national learning. The same caution should therefore be applied when interpreting data which represents the numbers of events recorded, and not the number of actual events that occurred. Data principles setting out how LFPSE data can and cannot be used are available here.

We publish quarterly official statistics in development on events recorded to the Learn from patient safety events (LFPSE) service. This quarterly publication is based on patient safety event records submitted between October 2024 and December 2024.

1.2 Patient Safety Incident Definition

The LFPSE service defines a patient safety incident as: ‘something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm for one or more person(s) receiving healthcare’. Full details of the definitions and harm gradings are available here.

LFPSE also captures three other patient safety event types: outcomes of concern, risks to patient safety, and instances of good care. Throughout this report, with the exception of table 1, we will be using patient safety incidents only, which constitute the vast majority of patient safety events data recorded to LFPSE. Future versions of this publication will encompass other event types.

2.1 Interpreting the data

National data collected by LFPSE comes mainly as a secondary use from what is recorded by staff into local risk management systems (LRMSs). Currently NHS acute providers submit most records we receive. However, anyone can record a patient safety event on the service: they may be healthcare staff from any NHS or private provider, patients or members of the public. LFPSE data is submitted voluntarily to foster openness and encourage continual increases in recording This means LFPSE data does not, and cannot, provide the definitive number of patient safety events occurring in the NHS; it measures the number of safety events recorded. The number of recorded safety events has increased year on year, which likely reflects improved recording culture and cannot necessarily be interpreted as the NHS becoming less safe. A ‘low’ recording rate for an organisation should not necessarily be interpreted as a ‘safe’ environment; it may represent under-recording. Conversely a ‘high’ recording rate should not be interpreted as ‘unsafe’; it may represent a more open culture. With this in mind, the calculated rates should not be used for direct comparisons between trusts. This document was extracted on 4th June 2025 and serves as a quarterly snapshot of the data currently held in LFPSE. Any figures reported are subject to change as records get updated into the system.

2.2 Missing values

Missing values have been handled and removed from the tables and plots, so the total counts will vary across tables.

2.3 Cleansing

Records that have been submitted with patient identifiable information and are yet to be anonymised will not appear in these data. Records that have submitted and subsequently updated that contain patient identifiable information, and are yet to be re-anonymised, will be displayed as their previous version in these data until anonymised.

2.4 Event types

LFPSE brings the feature to record patient safety event types beyond incidents. Recorders can now also upload patient safety risks, outcomes, and instances of good care. This is to ensure the database contains more instances of care that the healthcare system can learn from instead of only detailing errors involving patients. In the current period, 814,560 events were recorded to LFPSE, the majority of which were recorded as patient safety incidents (96.46%).

Table 1: Count of the event types in LFPSE

Based on patient safety event records submitted between October 2024 and December 2024.

Figure 1: Total patient safety incidents recorded per month for the NRLS and LFPSE

This plot illustrates the recording transition of patient safety incidents from the NRLS to LFPSE. Based on patient safety incident records from January 2021 to September 2024.

Table 2: Total patient safety incidents reported per month for the NRLS and LFPSE

This table illustrates the number of patient safety incidents per month recorded to the NRLS and LFPSE. Based on patient safety incident records from January 2021 to September 2024.

3.1 Psychological harm

LFPSE has a new variable for grading of the psychological harm associated with the recorded patient safety incidents. This is an experimental field which seeks to explore if responses to safety incidents need to be different if psychological harm is considered separately from physical harm, rather than rolling them together into one measure, as was done in the National Reporting Learning Service (NRLS). Currently, there is low confidence in the grading of psychological harm, as users familiarise themselves with its use, and as such, it is excluded from this report.

3.2 Physical harm

Grading the degree of harm to a patient resulting from a patient safety incident can be a challenge for recorders, but by grading patient safety incidents according to the harm they cause patients, local organisations can ensure consistency and comparability of data. This consistent approach locally will enable LFPSE to compare, analyse and learn from data nationally. This grading can also be used to “triage” incidents for review both locally and nationally, ensuring the most serious events are looked at first.

3.3 Harm policy

For more information on harm grading please see the harm grading policy guidelines.

Sometimes a problem in care can affect more than one patient, or none at all. To capture this, as a new feature of LFPSE, recorders can submit information for multiple patients per incident, meaning there can be multiple degrees of harm per incident. For the following figure and table we have taken the highest harm level per incident. During this quarter, 725,044 incidents had recorded a degree of harm. The majority of these incidents (93.67%) recorded low or no physical harm to patients.

Figure 2: Count of patient safety incidents by maximum physical harm

Based on patient safety incidents records submitted between October 2024 and December 2024.

Table 3: Count of patient safety incidents by maximum physical harm

Based on patient safety incidents records submitted between October 2024 and December 2024.