Patient safety incident reporting and learning system launched by
NPSA
Patient safety is again in the spotlight with the launch, in February, of the National Reporting and Learning Scheme (NRLS). The system, developed by the National Patient Safety Agency and believed to be a world first in a health care setting, draws together reports of patient safety errors and systems failures throughout England and Wales. Once recorded, information
will then be processed to spot recurring patterns, provide feedback and
potential solutions. The data will be used to prioritise the development
of safety solutions.
The NRLS works by extracting information from existing local risk management
systems, avoiding the need for NHS staff to carry out additional reporting.
Where a suitable local set-up does not exist, an electronic reporting form
is available. This “e-form” can also be used where staff will
only report an incident independently of their organisation, although the
NPSA stress that they encourage staff to share reports with their hospital
so that learning takes place both locally and nationally.
Information will be retained in an anonymous form only –– individual
staff or patients involved in patient safety episodes will not be recognised –– and
the NPSA will not themselves investigate incidents.
NPSA joint chief executive Susan Williams and Sue Osbourne pointed out
that: “In developing the NRLS we have drawn from the experience of
other sectors, such as the aviation industry, which shows clearly that
as reporting levels rise, the number of serious errors begins to decline.”
The system has been extensively tested. Nationwide roll-out is ongoing,
with at least 19 organisations already connected.
As organisations begin national reporting, their staff are also being offered
root cause analysis training from the NPSA to help pinpoint and tackle
the cause of patient safety incidents and support local analysis. Details
of the training courses and an e-learning toolkit are available here |
Hospital Pharmacist