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What is the Reporting and Learning System (RLS)?
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How is the RLS data collected?
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Why are these reports published?
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The data in these reports are classified as Official Statistics. What does this mean?
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How often will the reports be published?
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How do I interpret the data?
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How was the data set generated which was used in the first graph of the report?
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How was the data set generated which was used in the second and third graphs of the report?
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Why have some organisations changed cluster type?
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Why are the rates in the ambulance cluster not measured per 100,000 ambulance journeys?
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Why is the report for low reporting organisations different?
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Can the data that is used inthe graphs be viewed?
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Which organisation is the highest reporter and which is the lowest?
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Can the graph be expanded to cover the whole of England and Wales?
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Which other organisations are grouped together with my local organisation?
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My hospital is a high reporting hospital. Does that mean it is safe?
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My hospital is a low reporting hospital. Does that mean it is safe?
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What action will the NPSA take if an organisation is a consistently low reporter? Will the NPSA offer them particular support or guidance?
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What if the data in the NPSA summary report does not match the local organisations’ own records?
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Why does the total of reports submitted between October 2008 and March 2009 not add up to the number of incidents occurring during the same period?
The RLS was established in 2003. It helps identify hazards, risks and opportunities to improve the safety of patient care.
More information about the RLS.
The RLS 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 RLS.
More information about the RLS.
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 - particulalry those resulting in no or low harm - provides a real opportunity for the NHS and the NPSA to share experiences and learn from them.
In 2008, secondary legislation identified various Arms Length Bodies, including the NPSA, as providers of 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, 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.
The summary reports will be published every six months.
View an explanation of the summary report and how to interpret the data.
To help you understand the summary report we have prepared an
annotated sample report [PDF].
To allow organisations to benchmark themselves amongst their peers, the first graph shows the reporting rates of organisations form all regions across England and Wales categorised within the same cluster.
We have used the date when incidents occurred (between October 2008 and March 2009), where they were successfully submitted to the RLS by the end of June 2009.
A. We have used the incident date to derive the data sets for analytical reports. For comparative analysis purposes, the date the incident occurred is the more appropriate date to use: this date will not be affected by how frequently data is sent to the RLS.
The second and third charts are based on incidents which occurred between 1 October 2008 and 31 March 2009 and were reported to us by the end of June 2009.
A. For various reasons data issues may arise that mean the most appropriate denominator data from
Hospital Episodes Statistics or
Health Solutions Wales was unavailable. A suitable alternative denominator was available by changing cluster type for this organisation. Further information can be found in the
Data Handling Notes.
A. 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.
Low reporting organisations are those who have reported 10 or less incidents during the period of these reports. We have not produced a full report for this organisation as detailed feedback on a small number of incidents would be misleading. For example, an organisation reporting four incidents that resulted in low harm and one that resulted in severe harm would appear to have 20 percent of their incidents classified as severe. Further information can be found in the
Data Handling Notes.
A. There are two workbooks accompanying these reports, from which the data can be downloaded for analysis:
- Organisational level data , and
- Regional level data for SHAs and Wales
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 – so resulting in better and more established reporting amongst all staff.
A. 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 the charts because the different groups do not have the same denominator for calculating rates. In Wales for example, a number of organisations provide both general acute and mental health services. To enable organisations to be compared with similar services, two reports are produced, one for incidents reported from the acute care setting and one for the mental health care setting.
A. Organisations are grouped into those which provide similar services, e.g. primary care organisations are grouped together, teaching hospitals together etc. View organisation categories.
It has been recognised that the higher the organisational reporting rate, the stronger the reporting and learning culture will be locally. More information about reporting.
It has been recognised that the higher the organisational reporting rate, the stronger the reporting and learning culture will be locally.
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 RLS. We also have projects underway to promote reporting from low reporting services, such as primary care.
This NPSA data set is based on the date an incident report was successfully submitted to the RLS. Incident reports have been included if they occurred between 1 October 2008 and 31 March 2009, and were successfully submitted by 30 June 2009. If the number of reports in the local database is different, this may be because the incidents were not submitted to the RLS by the end of November, or because the incidents did not meet national data quality checks (incident reports may be rejected by the RLS if mandatory fields are not completed).
This is because the first counts all the patient safety incidents successfully submitted by your organisation to the RLS during the period 1 October 2008 and 31 March 2009. The latter shows the total of patient safety incidents occurring between 1 October 2008 and 31 March 2009 which were successfully submitted to the RLS by the end of June 2009.
