Patient safety reporting overhaul

The NHS is developing the National Reporting and Learning System to become an integrated reporting route for patient safety incidents.

The system was previously run by the National Patient Safety Agency and is used to report and analyse patient safety incidents such as falls or surgical errors.

However, it has taken a back seat since the closure of the agency in June 2012, when responsibility was transferred to NHS England.

There are two national reporting systems for patient safety in the NHS; the NRLS and one run by the Medicines and Healthcare Products Regulatory Agency. This causes inconsistency as some incidents will be reported to both systems, while others will only be reported to one of them.

NHS England and the MHRA are working together on the new development, which will join these two systems via an integrated reporting route, meaning all reporting, information and feedback on incidents will go through the same system locally and nationally.

The organisations have also drafted two new Patient Safety Alerts documents; one on ‘improving medical device incident reporting and learning’, and one doing the same for medication errors.

“Further integration of local and national systems for reporting and learning about medical device incidents in the NHS, will improve the early detection of risks and enable actions to reduce harm to patients,” says the paper.

“Essential reporting information will only need to be entered once at local level and it will then be available to local and national learning systems.”

The integration means information on the incidents will need to be gathered and included in local risk management systems and sent immediately to the NRLS.

The draft alerts are out to consultation until 8 December. NHS England is looking for responses from healthcare professionals before they are issued.

The government’s full response to the Francis Inquiry, released last week, made a strong commitment to a new patient safety improvement programme. The programme is led by NHS England and includes re-launching the patient safety alert system by the end of this year.

This will include greater clarity about how NHS bodies can assess compliance with alerts and ensure they are implemented properly.

NHS England and the MHRA are also developing enhanced governance systems, improved feedback systems and a National Medical Devices Safety Network.

The network will provide a new forum for discussing potential and recognised safety issues, identifying trends and suggesting actions to improve patient safety,” the response says.

“The network will also work with new Patient Safety Improvement Collaboratives that will be setup during 2014”