NPSA set to overhaul its National Reporting and Learning System
An overhaul of NRLS is included in the DoH’s “safety first” report |
Other recommendations in the DoH report
• All incidents should be considered locally within 24 hours of
being reported and the NPSA should be notified within 36 hours
of events that involve serious patient harm
• The NPSA should work in partnership with agencies that gather
data, such as complaints, claims and coroners reports, to ensure
that all incidents associated with death and serious harm are
identified |
Redesigning the National Patient Safety Agency’s
National Reporting and Learning System (NRLS) is one of the recommendations
of “Safety
first: a report for patients, clinicians and health care managers,” published last month by the Department of Health.
The report is the result of a review commissioned by the Chief Medical
Officer for England to address issues raised in the National Audit Office
report “A safer place for patients: learning to improve patient
safety.” The report looks more widely at the approach to patient
safety in the NHS.
Despite the large number of incident reports received, the review found
little evidence that the NRLS is producing a complete and accurate picture
of the major safety problems faced by the NHS. Reasons for this include
an awareness that many incident reports contain inaccurate or incomplete
information about patient harm and there is insufficient involvement
of local NHS organisations in reviewing and acting upon analysis of their
own incident reports.
Recommendations for improvement include suggestions that reports should
be simplified and a new category of “incidents that could happen” should
be added.
In a separate development, further inadequacies in the data
feeding into the NRLS have been highlighted. Research published by BMJ
Online First on 15 December 2006 suggests that hospital reporting
systems may be significantly under-reporting the scale and severity of
incidents.
In the study, the number and type of incidents in a random sample of 1,006 admissions
in a large NHS hospital in England, identified by reviewing medical notes, were
compared with data extracted from the trust’s routine reporting system.
Of the 324 incidents that occurred, case review identified 303 incidents, while
just 54 were recorded in the reporting system, which also missed 71 drug-related
problems.
“The results do not mean that the early themes emerging from the analysis
of the
national reporting system are not useful”, the authors state, “but
estimates of the type and severity of incidents are likely to be biased.” |
Hospital Pharmacist