National Reporting

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National Reporting Learning System (NRLS)
Reporting systems are vital in providing a core
of sound, representative information on which to
base analysis and recommendations An
Organisation with a Memory Chris Foye Knowledge
Architect 3 May 2004
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About the NPSA

• Agency established in July 2001
• Purpose

implement and operate a new national system for
learning from patient safety incidents in all
sectors of the NHS with one core purpose to
improve patient safety by reducing the risk of
harm through errorBuilding a Safer NHS for
Patients
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Definitions

• What do we mean by patient safety?

The processes by which an organisation reduces
the risk and occurrence of harm to patients as a
result of their healthcare
What is a Patient Safety Incident (PSI)?
Any unintended or unexpected incident(s) that
could have or did lead to harm for one or more
persons receiving NHS funded healthcare
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What is the NRLS?

• A system for the NHS in England and Wales which
  allows
• Health care organisations and staff to report to
  the NPSA electronically details of any patient
  safety incident
• A database of reliable high quality data
• Statistical and analytical reporting tools
• A tool to support the implementation of an open
  fair culture with the aim of improving patient
  safety

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Aims
Assimilate other PS information
Store anonymised information
NHS staff / Public / Patient / Reporting
Identify and record PSIs
Help the NHS to learn from PSIs

• Preventative
• Solutions

Inform development of national solutions
Not punitive
Supplement local reporting learning
Minimise reporting burden
Discover patterns contributing factors
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NRLS Evolution
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NRLS development

• Patient safety incident dataset development
  following
• Pilot 20 sites 18 of which reported PSIs
• TD 39 sites 37 of which reported PSIs
• Usability reviews
• Thinktank input from
• Care professionals
• Stakeholders
• Information experts
• NPSA staff
• Chief Medical Officer support sign off
• Rollout to 635 Trusts across England Wales
• Regular reviews and revisions planned

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Learning from pilot data

• Evidence to support many ongoing projects
• Consistent data mapping
• Ensure data quality
• Need to have Trust Id
• Importance of bounceback / feedback
• Identified a previously unknown cluster of PSIs
  relating to adverse reactions to contrast media

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The reporting gap identified
Rate
Incident rate
10.8
(Per C.Vincent et al)
3.0
Reporting rate
2.5
(Per NPSA pilot and TD data)
0
Time
Professor Vincent is an internationally renowned
expert on patient safety, clinical risk
management and adverse event analysis. He is also
a Commissioner for the UK Commission for Health
Improvement.
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NRLS dataset evolution

• Over 1200 issues logged during TD stage
• Number of fields reduced by 25
• Incident categories reduced by nearly 70
• Includes contributory factors
• Contains 3 types of fields for action to
• Prevent reoccurrence
• Prevent incident affecting patient (near miss)
• Minimise harm
• Unified taxonomy covering all service areas

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Incident category

• Simplification
• High level generic terms
• Applicable for the whole service
• Free text
• Key to picking out specifics
• Categorisation software

Courtesy of NHSIA website
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Top level incident categories

1. Access, admission, transfer, discharge
2. Clinical assessment (incl. diagnosis, tests,
   assessments)
3. Consent, communication, confidentiality
4. Disruptive, aggressive behaviour
5. Documentation (including records, identification)
6. Infection control

• G. Implementation and ongoing monitoring/review
• H. Infrastructure (including staffing,
  facilities, environment)
• I. Medical device, equipment
• J. Medication
• K. Patient abuse
• L. Patient accident
• M. Self harming behaviour
• N. Treatment, procedure
• Other

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Contributory factors

• Communication
• Education training
• Medication
• Equipment resources

• Organisation strategic
• Working conditions
• Team and social
• Task factors
• Patient factors

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Grading of Incidents