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About reporting patient safety incidents

We manage a national reporting system on behalf of the NHS in England and Wales. This is known as the National Reporting and Learning System (NRLS).

 

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 should be reported to the NRLS and we will then report them to the Care Quality Commission. Further information is available from the Care Quality Commission.

 

National Reporting and Learning System (NRLS)

The NRLS was established in 2003. The system enables patient safety incident reports to be submitted 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 four million incident reports have been submitted by healthcare staff.

 

The NRLS is a pioneer and is the most comprehensive of its kind in the world. It uniquely provides the NHS with a national perspective on risks and hazards. This information is used to develop tools and guidance to help improve patient safety at a local level.

 

Most incidents are submitted to the NRLS electronically from local risk management systems.

 

 

How reports are used

Reports to the NRLS are analysed with expert clinical input to identify common hazards.

Recommendations can be made to local NHS organisations to mitigate these risks and improve the safety of patient care. 

 

Information from reported incidents helps the NHS understand why things go wrong and how to stop them happening again. 

 

Within a local NHS organisation, a serious event may be perceived as a one-off. Reporting to the NRLS can reveal similar incidents in other parts of the NHS and can also help identify learning from incidents in different organisations.

 

The NRLS helps NHS organisations understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent future harm to patients.



The NRLS individually reviews all reports of patient death or serious harm.  NRLS staff work with the NHS, clinical experts and safety experts to develop and disseminate safety alerts and recommendations across the NHS.

 

High and low reporting organisations

Organisations with a culture of high reporting are more likely to have developed a strong reporting and learning culture. 


Experience from other industries indicates that as an organisation’s reporting culture matures, staff become more likely to report incidents. 

 

Five actions to improve patient safety reporting

The NRLS, the NHS Confederation and a group of high reporting acute trusts have jointly developed a better understanding of what good reporting looks like and how it can be achieved.