Working towards a national surveillance system for patient safety The National Reporting and Learning System and the Pat

1. Working towards a national surveillance system for patient safetyThe National Reporting and Learning System and the Patient Safety Observatory Sarah Scobie Head of Observatory National Patient Safety Agency UK

2. To err is human To cover up is unforgivable To fail to learn is inexcusable Sir Liam Donaldson Chief Medical Officer England

3. Purpose of the NPSA Special health authority with mandate to: • implement a national reporting system for patient safety incidents • collect and appraise information to promote patient safety • provide advice and guidance and monitor its effectiveness • promote research which contributes to patient safety • report and advise Ministers on matters affecting patient safety

4. Overview • The National Reporting and Learning System • The Patient Safety Observatory: what is it and why do we need it? • The Observatory work programme

5. The National Reporting and Learning System (NRLS) • Confidential reporting database • Incidents are reported electronically – 99% come from Local Risk Management System • Analysis of data at national level to • identify trends and patterns • provide feedback for local action • inform NPSA work programmes

6. Number of incidents and reporting trusts

7. Approaches to analysis of NRLS data • Routine monitoring reports • Thematic analysis • Ad hoc analysis • Exploratory • Reviews of selected incidents • Data mining

8. Routine and thematic reports • Trust feedback reports • Quarterly overview • Thematic reports

10. Ad hoc analysis • Requests from NHS clinicians and risk managers, and relating to current NPSA projects • Use of categorical data supplemented by sophisticated text searching tool • Examples during one week: • epidurals, following fatal incident, to inform an NPSA fast track project on epidural infusions • chairs, for an external enquiry • Midwifery and Obstetrics, for Litigation Authority event on maternity risk management • screening tests for Down's Syndrome, following software issue identified in a trust • systemic dermatology treatments • blood glucose monitors, following issue identified by the regulator for medical devices • wrong route administration of oral liquid medicines, to support the preparation of a patient safety alert

11. Systematic review of incidents • Richness of NRLS data in free text descriptions review from clinical perspective adds value • Huge volumes of data – sampling by specialty and incident type • Tools to support robust and consistent review of data supported by guidance decision tree for follow-up action

12. Data-mining Pattern-search Looking for small localised patterns in the data Able to look through high-dimensional data (categorical and free text) Able to pick out small unknown patterns that may represent a trend in patient safety Model building and hypothesis testing

13. Why do we need a PSO? • Incident data not the only source • Systematic surveillance and analysis of NRLS and other data

14. Settings of incidents reported to the NRLS Source: Reports in the NRLS database up to 31 March 2006

15. Trend in reporting rates with time since connection to NRLS

16. Other datasets. • Clinical negligence • MHRA • Hospital Episodes • GP Databases Patient Safety Research OTHER ORGANISATIONS Surveillance & Monitoring OBSERVATORY PRIORITISATION Other confidential reporting systems SOLUTIONS NRLS EVALUATION • Intelligence • Healthcare Commission • Expert Groups • Patient/Public • DH/Ministers • Interest Groups etc. NHS Feedback & Bounceback R&D Research Public/Patient eForm PATIENTS/ PUBLIC

17. The Patient Safety Observatory at Work : MRI scanners • NRLS data: 500 reports; 31 related to implants; five pacemakers, one implantable defibrillator, one heart valve and three aneurysm clips went undetected • PSO: Litigation relating to pacemaker/MRI fatality; 200 incidents reported to medical device regulator; local visits: • frontline staff depending on constant vigilance rather than safer systems • Prioritisation process: report to NPSA Board this month

18. PSO at work: collaboration with other organisations • Hospital episode statistics – developing patient safety indicators based on AHRQ • Clinical negligence: NHS Litigation Authority and medical negligence organisations • Safety culture and processes: NHS staff survey

19. Indicators from administrative data • replicate AHRQ analysis for a sub-set of indicators • mapping coding definitions to ICD10/OPCS4 • age and sex standardised indicators derived at national and trust level, as per specifications • validation: length of stay and mortality (cases compared with matched controls) • comparison with US results

20. Preliminary results: rates per 1000 discharges

21. Preliminary results: excess length of stay (days)* * Cases vs matched controls

22. Patient Safety Observatory - summary • Systematic analysis • No one source of data is sufficient • Collaboration between relevant organisations • Results: • Investigating and reporting back • Better use of existing data • Path to integrated approach to patient safety surveillance

23. Thank you sarah.scobie@npsa.nhs.uk