Local reporting systems

Safety in the context of healthcare is often compared unfavourably with other industries such as aviation and the nuclear power industry. These high-risk industries have embraced incident reporting as a way of learning from safety incidents and also recording near misses and low-harm events. This reporting provides vital learning by providing information about systemic issues which have the ability to cause catastrophic harm to patients in the future.

In healthcare, however, evidence suggests that only between 5-15% of patient safety incidents are reported. There are several contributing factors for this, which include:

  • fear of punitive action
  • lack of confidence in reporting systems and
  • time-consuming reporting processes

There are a number of ways to improve local reporting, as described by the National Reporting and Learning System website. These include:

  • ensuring quality reporting by adhering to the Data Quality Standards. Better education and training should be provided to allow staff to understand what constitutes a good incident report.
  • engaging of frontline staff and management by sharing safety reports with staff and developing a no-blame culture
  • regular reporting. Incident reports should be submitted to the National Reporting and Learning System (NRLS) at least monthly. The RLS is a national collection system that reviews and analyses data relating to patient safety risks. Following analysis, it also feeds back data, learning and future actions required for organisations to improve. Service planners should be aware, however, that NHS England is currently considering options for an upgraded successor, the Patient Safety Incident Management System (PSIMS) due to be delivered in 2018.
  • prompt reporting to ensure lessons learnt can be passed on quickly to prevent harm to others
  • making reporting matter. A correctly implemented reporting system should provide safety information, feedback, learning and improvement actions taken.
  • ensuring consistency of coding so that comparison and analysis of data can be done nationally to improve patient safety

Serious incidents and never events

Serious incidents are defined by NHS England’s Revised Serious Incident Framework (2015) as ‘events in health care where the potential for learning… or the consequences… are so significant, that they warrant using additional resources to mount a comprehensive response’. This framework also outlines the identification of serious incidents as well as the Serious Incident Management Process, which covers the conducting of investigations in order to prevent recurrence.

Aside from serious incidents, special attention must also be paid to ‘never events’. These are a particular subset of wholly preventable serious incidents that are known to have occurred in the past (eg through NRLS reports) with the potential to cause serious patient harm or death. These include events such as wrong-site surgery, retained foreign-object post-operation, incompatible blood transfusion, incorrect preparation and delivery of high-risk injectable medications.

These events are very rare in healthcare but the outcomes can be catastrophic for patients. As such they must always be investigated and acted on. NHS England has created a Never Events Policy and Framework that can be used to guide management of these situations as well as regularly updated lists of incidents considered within this category. Never event data can be obtained from the NHS Improvement website, updated on a monthly basis.