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Building a memory

Reference number
Issue date18 September 2005
TypeData report

This Patient Safety Observatory report provided an analysis of reported patient safety incidents and emerging trends from November 2003 to March 2005.


The report was based on information from 230 organisations, which together reported 85,342 patient safety incidents to the Reporting and Learning System (RLS). Most of these incidents (68 per cent of the total) resulted in no harm to patients. Of the reported incidents, about one in 100 led to severe harm or death.


It presented a unique overview of patient safety issues in the NHS, including:

  • an analysis of reports made, including a breakdown of reports from different healthcare settings;
  • an analysis of patient safety incidents and emerging issues;
  • an analysis of reported deaths;
  • a comparison of reports to the RLS with other sources of information about patient safety, including international research; and
  • case studies.


It outlined the ways in which the National Reporting and Learning Service planned to develop use of the data received. It also described how the Patient Safety Observatory makes full use of incident reports alongside other data sources.

Building a Memory - PSO Report
Building a Memory - PSO Report - 302 KB 0222 - Building a Memory - PSO Report - 2005-07 - V1