On 12 September 2012 the NHS Commissioning Board Authority published the latest set of Organisation Patient Safety Incident data1,2.
The figures show that the number of patient safety incidents in England that occurred between 1 October 2011 and 31 March 2012 and were submitted to the National Reporting and Learning System (NRLS) by 31 May 2012 was 612,414. This is an increase of 2.3 per cent compared to the previous reporting period (1 April 2011 to 30 September 2011.)
The NRLS is a voluntary reporting tool. It captures, analyses and feeds back patient safety incident reports to the NHS. Reporting and analysis of safety related incident reports, including incidents resulting in no or low harm, provides an opportunity to reduce the risk of future incidents through learning.
90 per cent of trusts in England submitted incident reports to the National Reporting and Learning System for this set of data. 53 per cent of organisations reported monthly during this period, compared with 59 per cent last time.
The data demonstrates that there is increased reporting of incidents to the National Reporting and Learning System, maintaining improvements in reporting culture. The data also shows that:
413,459 (68 per cent) of patient safety incident reports resulted in no harm to the patient;
154,681 (25 per cent) resulted in low harm;
39,039 (six per cent) resulted in moderate harm;
5,235 (one per cent) resulted in death or severe harm.3,4
The most common types of incident reported were: patient accidents– slips, trips and falls (26 per cent); medication incidents (11 per cent); incidents relating to treatment and/or procedures (11 per cent). This trend remains consistent with previous data releases.
From October 2011 NHS organisations now report to the NRLS incidents of apparent or actual suicides of people with an episode of care relevant to their suicide, following a revision in guidance on reporting by the Care Quality Commission5,6 .Consequently, the Mental Health cluster shows an increase in reported deaths of 70 per cent (from 474 to 806 deaths.) Figures on confirmed suicides by Mental Health patients are published annually by the National Confidential Inquiry into Suicide and Homicide7.
Excluding deaths in the Mental Health cluster, the number of deaths reported for all care settings decreases from 760 to 746 for the current reporting period, a 2 per cent decrease8,9.
The data shows an increase in no and low reporting organisations, with a total of 101 organisations classed as no or low reporters for the current round of reports. This is compared with 66 organisations in the last report. 100 of the no and low reporting organisations are Primary Care Trusts with no-inpatient provision (commissioning only)10.
Mike Durkin, Director of Patient Safety, NHS Commissioning Board Authority, said: “The NHS Commissioning Board Authority is working to ensure the new system will drive improvements in patient safety. NHS organisations should use this data and review the tools, guidance and support available to them. This will ensure patient safety incidents continue to be reported and learned from, strengthening the patient safety culture across all levels of the NHS.”
For a full breakdown of figures on a trust-by-trust basis see: www.nrls.npsa.nhs.uk/organisationdata
Notes to editors
1. Media enquiries to Matthew Grek in the NHS Commissioning Board Authority:
Telephone: 0774 776 8334
2.This data is published by the NHS Commissioning Board Authority. This follows the transfer of key functions and expertise for patient safety developed by the National Patient Safety Agency (NPSA) on Friday 1 June 2012.
3.Reporting of degree of harm in the NRLS is intended to record the actual degree of harm suffered by the patient. However due to large number of organisations/people reporting to the NRLS this is not always the case.
An analysis of incidents from the NRLS reported as resulting in death between 1 October 2011 and 31 March 2012 has shown that 69per cent of these incidents are events in which the death of the patient was, or might have been, directly related to patient safety. Some incidents may be coded based on the potential harm to the patient, rather than the actual harm. In other cases, the patient may have died, but not as a result of a patient safety incident: even following investigation, the relationship between any incident which occurred and the outcome for the patient is often unclear, as many incidents happen during the care of patients with life-threatening illness.
4. Definitions of levels of harm:
Impact prevented – any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm to people receiving NHS-funded care.
Impact not prevented – any patient safety incident that ran to completion but no harm occurred to people receiving NHS-funded care.
Low: Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving NHS-funded care.
Moderate: Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care.
Severe: Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care.
Death: Any patient safety incident that directly resulted in the death of one or more persons receiving NHS-funded care.
5. Revised guidance on reporting serious patient safety incidents
From 1 April 2010 it became mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process. To avoid duplication of reporting, all incidents resulting in death or severe harm are reported to the NRLS and these are then shared with the Care Quality Commission.
6. Revised guidance on reporting suicide and severe self harm
From October 2011, the Care Quality Commission required the following to be reported to the NRLS:
“all apparent or actual suicides of people with an open episode of care in your organisation relevant to their suicide/ self harm (either community or inpatient) at the time of death.”
Previous guidance stated that a reportable outpatient suicide should be linked with a patient safety incident rather than regarding the suicide itself as an incident.
7.Figures on confirmed suicides by Mental Health patients are published annually by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: http://www.medicine.manchester.ac.uk/cmhr/centreforsuicideprevention/nci/
8. The suicide prevention toolkit provides mental health organisations with a simple method to:
• Establish a system for suicide audit in the local context
• Use case note reviews to change how performance is measured and risks are identified
• Support the development of local suicide prevention strategies
• Produce data which can be merged at regional and national levels to identify trends for further learning.
Further information: http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65297
9.Suicide prevention strategy
On 10 September 2012 the Department of Health launched a new suicide prevention strategy.
Further information: http://mediacentre.dh.gov.uk/2012/09/10/new-suicide-strategy-and-1-5-million-into-prevention-research/
10.The Transforming Community Services Programme (TCS) has resulted in the transfer of inpatient services to a number of different providers, many to non NHS organisations including local authorities and social enterprises. TCS has also increased the number of commissioning only Primary Care Trusts (PCTs). Therefore, the number and pattern of incidents reported from primary care will be very different to previous Organisation Patient Safety Incident Reports.