National Reporting & Learning System (NRLS)

1. 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

2. 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 error”Building a Safer NHS for Patients

3. 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

4. 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

5. Develop comprehensive national picture of trends and patterns for reported incidents 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

6. NRLS Evolution

7. NRLS development • Patient safety incident dataset development following • Pilot 20 sites 18 of which reported PSIs • T&D 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

8. 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

9. Reporting Gap The reporting gap identified Rate Incident rate 10.8% (Per C.Vincent et al) 3.0% Reporting rate 2.5% (Per NPSA pilot and T&D 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.

10. NRLS dataset evolution • Over 1200 issues logged during T&D 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

11. 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

12. Access, admission, transfer, discharge Clinical assessment (incl. diagnosis, tests, assessments) Consent, communication, confidentiality Disruptive, aggressive behaviour Documentation (including records, identification) 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 Top level incident categories

13. Organisation & strategic Working conditions Team and social Task factors Patient factors Communication Education & training Medication Equipment & resources Contributory factors

14. Patient Safety Incident No Harm Low Moderate Severe Death Impact prevented Impact not prevented Prevented PSI / Near Miss Grading of Incidents