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 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: 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 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 Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving NHS funded healthcare What is a Patient Safety Incident (PSI)?

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 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. Aims Discover patterns & contributing factors Minimise reporting burden Not punitive Store anonymised information Identify and record PSIs Supplement local reporting & learning Help the NHS to learn from PSIs NHS staff / Public / Patient / Reporting Assimilate other PS information Inform development of national solutions Preventative Solutions Develop comprehensive national picture of trends and patterns for reported incidents

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 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 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. The reporting gap identified Rate Time 0 0 2.5% 3.0% 10.8% Incident rate Reporting rate (Per C.Vincent et al) (Per NPSA pilot and T&D data) Reporting Gap 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 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 Simplification High level generic terms –Applicable for the whole service Free text –Key to picking out specifics Categorisation software Courtesy of NHSIA website

12. Top level incident categories A.Access, admission, transfer, discharge B.Clinical assessment (incl. diagnosis, tests, assessments) C.Consent, communication, confidentiality D.Disruptive, aggressive behaviour E.Documentation (including records, identification) F.Infection control A.Access, admission, transfer, discharge B.Clinical assessment (incl. diagnosis, tests, assessments) C.Consent, communication, confidentiality D.Disruptive, aggressive behaviour E.Documentation (including records, identification) F.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 Z.Other

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

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