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Organisation Patient Safety Incident Reports


Tenth data release: 25 September 2013

The tenth release of the Organisation Patient Safety Incident Reports data for NHS organisations in England and Wales took place on Wednesday 25 September 2013 . 

 

The data release will include details of patient safety incidents in England and Wales that occurred between 01 October 2012 and 31 March 2013 and were submitted to the National Reporting and Learning System (NRLS) by the end of May 2013. 

 

Future data release

The eleventh release of the Organisation Patient Safety Incident Reports data for NHS organisations will take place at the end of April 2014

 

 

View Organisation Patient Safety Incident Reports.

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About the data

  • The data contain a breakdown of patient safety incident reports.
  • Information is broken down by incident type and degree of harm. 
  • The data include comparative information on rate and consistency of reporting.

 

Incident summary for the period

The data show the total number of incidents during a six month period. These are broken down by incident type and degree of harm. 

 

Incident type

Incidents are indexed by the following categories:

  • Patient accident
  • Treatment, procedure
  • Medication
  • Access, admission, transfer, discharge
  • Documentation (including records, identification)
  • Infrastructure (including staffing, facilities, environment)
  • Clinical assessment
  • Implementation of care and ongoing monitoring / review
  • Consent, communication, confidentiality
  • Medical device / equipment
  • All others categories

 

 

Degree of harm

The incidents are categorised by degree of harm as follows:

  • No harm
  • Low harm
  • Moderate harm
  • Severe harm
  • Death

 

Degree of harm is coded by the healthcare organisation at a local level. Please note there is wide variation in how different healthcare organisations code their incident reports

 

 

Reporting level summary

We encourage high reporting. Scrupulous reporting and analysis of safety related incidents, particularly incidents resulting in no or low harm, provides an opportunity to reduce the risk of future incidents. Research shows that organisations which report more usually have a stronger learning culture where patient safety is a high priority. Through high reporting the whole of the NHS can learn from the experiences of individual organisations. See Five actions to improve patient safety reporting for more information.


Frequently asked questions


  1. What is the National Reporting and Learning System (NRLS)?
  2. How is the NRLS data collected?
  3. Why are these data published?
  4. In what format are the data published?
  5. The data are classified as Official Statistics. What does this mean?
  6. How often are the data published?
  7. Why are the rates in the ambulance cluster not measured per 100,000 ambulance journeys?
  8. Which organisation is the highest reporter and which is the lowest?
  9. Can the data be expanded to cover the whole of England and Wales?
  10. Why have the clusters of primary care organisations changed
  11. Which other organisations are grouped together with my local organisation?
  12. My hospital is a high reporting hospital. Does that mean it is safe?
  13. My hospital is a low reporting hospital. Does that mean it is safe?
  14. What action will be taken if an organisation is a consistently low reporter?  Will they be offered any particular support or guidance?
  15. What if the data in the summary report does not match the local organisations’ own records?
  16. What happens to this data following the abolition of NPSA?


  1. What is the National Reporting and Learning System (NRLS)?

    The NRLS was established in 2003. It enables patient safety incident reports to be submitted from NHS organisations to a national database. This data is then analysed to identify hazards, risks and opportunities to improve the safety of patient care. Since the NRLS was established, over six million incident reports have been submitted by healthcare staff.  The NRLS is the most comprehensive reporting and learning system of its kind in the world.  
  2. How is the NRLS data collected?

    The NRLS collects data on patient safety incidents in England and Wales. Most incidents are submitted electronically from local risk management systems. Organisations vary in how their local systems are set up, how many incidents are reported locally and how frequently they send data to the NRLS.  More information about the NRLS.

  3. Why are these data published?

    These data are an important tool to support boards of NHS organisations to analyse their performance and trends of reporting so they can develop action plans to increase levels of patient safety. This greater level of transparency, together with more thorough reporting and analysis of safety-related incidents, particularly those resulting in no or low harm, provides a real opportunity for the NHS and the NRLS to share experiences and learn from them. 


  4. In what format are the data published?

    From September 2011 release the data are published as data workbooks (in excel and csv formats) with supporting two-page (Adobe PDF) reports for each NHS organisation, presenting the data in graphical form. Adobe Reader 6.0 or above requiredDownload Adobe Reader.
  5. The data are classified as Official Statistics. What does this mean?

    Thes data are indentified as Official Statistics. A general definition is that these are statistics at national level, which are of public interest. The production of such statistics should follow the Statistics Code of Practice, ensuring consistency and quality which should increase public confidence in the data. The publication of such data must also follow a code of practice, with pre-release access strictly limited and released on a pre-specified date.


  6. How often are the data published?

    Every six months, in March and September.

  7. Why are the rates in the ambulance cluster not measured per 100,000 ambulance journeys?

    For ambulance trusts we had previously calculated the rate of reported incidents per 100,000 journeys. Feedback from a stakeholders stressed that this was not appropriate denominator.
     
    We are aware that directly comparing the number of reports received from organisations with other ambulance organisations can be misleading, as ambulance organisations can vary in size and activity. We are currently looking into ways to make comparisons across this cluster more effective.

  8. Which organisation is the highest reporter and which is the lowest?

     

    Comparisons across all organisations are not meaningful as different clusters of organisations would reasonably be expected to have different rates of reporting. It is most often the case that those organisations which report more have a stronger learning culture where patient safety is a high priority.   
     

  9. Can the data be expanded to cover the whole of England and Wales?

     

    Organisations are grouped into those which provide similar services, e.g. primary care organisations are grouped together, teaching hospitals together etc. This makes the comparisons more meaningful. View organisation categories. It is not possible to combine cluster types because the different groups do not have the same denominators for calculating rates.

 

10. Why have the clusters of primary care organisations changed?

Transforming Community Services (TCS) is a DH programme of work set up to implement changes in Primary Care Trusts (PCTs) to support Commissioning by removing all clinical service provision from PCTs. The NHS Operating Framework 2010/11 mandates that all PCTs divest themselves of this provision by April 2011.

 

In order to accommodate these changes we have amended our clusters so that all commissioning PCTs will now be allocated to the PCO - no inpatient provision cluster and NHS organisations where the main provision is community services have been allocated to the PCO - inpatient provision cluster.

 

We understand that some organisations may not have completed the transition during the period that these reports cover and could still be reporting incidents from inpatient services, however, for consistency these will remain in the no inpatient cluster. NHS organisations where the main provision is community services have been allocated to the PCO - inpatient provision cluster.

 

We understand that the naming of this cluster does not wholly reflect the nature of community NHS trusts but for simplicity and while organisational structures are still in transition we will retain this cluster name and may take a decision to rename clusters in the future.

 

Further information is in the data handing notes.

 

11. Which other organisations are grouped together with my local organisation?

Organisations are grouped into those which provide similar services, e.g. primary care organisations are grouped together, teaching hospitals together etc. View organisation categories (cluster types).

12. My hospital is a high reporting hospital. Does that mean it is safe?

We encourage high reporting. Scrupulous reporting and analysis of safety related incidents, particularly incidents resulting in no or low harm, provides an opportunity to reduce the risk of future incidents. Research shows that organisations which report more usually have a stronger learning culture where patient safety is a high priority. Through high reporting the whole of the NHS can learn from the experiences of individual organisations. 

 

 

13. My hospital is a low reporting hospital. Does that mean it is safe?

In most cases where NHS organisations have reported only a small number of patient safety incidents it is because reports are being received locally but not all are being uploaded nationally. We have found that the most common problems include technical or local resource issues and we are working with low reporting organisations to overcome these issues. 

 

14. What action will be taken if an organisation is a consistently low reporter? Are they offered any particular support or guidance? 

We encourage consistent, high reporting, which provides organisations with more opportunities to learn from incidents and improve safety. Research has found that high reporting is associated with other indicators of a strong safety culture. 
 
We are concerned about organisations with low or inconsistent reports, and provide support and guidance to organisations with difficulties reporting to the NRLS.  


15. What if the data in the summary report does not match the local organisations’ own records?

This data set is based on the date an incident report was successfully submitted to the NRLS.  Incident reports have been included if they occurred between 1 October 2011 and 31 March 2012 and were submitted by 31 May 2012. If the number of reports in the local database is different this may be because the incidents were not submitted to the NRLS by 31 May 2012, or because the incidents did not meet national data quality checks (incident reports may be rejected by the NRLS if mandatory fields are not completed).


16. What happens to this data following the abolition of NPSA?

It is important that NHS organisations continue to submit their patient safety incident reports to the National Reporting and Learning System (NRLS). The NRLS will continue to receive reports of patient safety incidents and the responsibility for oversight will move to the NHS Commissioning Board.  

These data workbooks cover organisation patient safety incident report data for incidents that occurred between 1 October 2012 and 31 March 2013 and were submitted to the National Reporting and Learning System (NRLS) by the end of May 2013.