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Nigel's surgery 24: Reporting patient safety incidents to the National Reporting and Learning System (NRLS) for GP practices

Categories:
  • Organisations we regulate

When we inspect GP practices, one of our key questions is if practices are providing safe care.

We look at how practices:

  • identify safety issues
  • record safety incidents, concerns and near misses, and
  • report and respond to these internally and externally (where appropriate).

During an inspection, we look at the practice’s processes and systems to monitor patient safety. We look at reporting of patient safety incidents. We also look at practice’s learning from these incidents and significant events.

This Mythbuster is about reporting patient safety incidents to the National Reporting and Learning System (NRLS). NRLS has introduced a referral eForm. This allows the learning to be used in the practice’s significant event analysis programme.

What is the NRLS?

NRLS enables practices to submit patient safety incident reports to a national database (NLRS data). It was designed by the National Patient Safety Agency based on international experience and best practice. It helps make sure learning gained from patient experience in one part of the country is used to reduce risk elsewhere.

How to report a patient safety incident to the NRLS

Patient safety incidents can be reported via local reporting management systems or directly to NRLS. This uses an electronic reporting form (referral eForm). The eform contains enhanced features to enable quick and easy completion. It also has a Continuing Professional Development/Significant Event Analysis reflective template. This enables rapid documentation of learning and impact for CPD, appraisal and revalidation.

What should be reported?

All patient safety incidents should be reported through NRLS. A patient safety incident can be defined as:

  • any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare.

All levels of harm, defined below, should be reported even if no actual harm to the patient has occurred.

Term Definition Clinical example
No harm Any patient safety incident that did not result in harm or injury or that had the potential to cause harm but was prevented, resulting in no harm (near miss) A GP prescribes the twice the recommended dose of a new drug. The local community pharmacist picks this up when dispensing the prescription.
Low harm Any patient safety incident needing extra observation or minor treatment A patient’s home visit is missed. The patient has cellulitis of the right leg, which was picked up the following day. This resulted in the GP deciding to prescribe I.V. rather than oral antibiotics which need to be delivered by community frailty team.
Moderate harm Any patient safety incident resulting in a moderate increase in treatment. The incident caused significant but not permanent harm. Continuing treatment with warfarin without monitoring INR for 6 weeks longer than had been intended. The patient had an upper GI bleed and was admitted to hospital for 5 days for monitoring and follow-up. It was noted on admission that the INR was 7.
Severe harm Any patient safety incident that appears to have resulted in permanent harm. A patient who is a heavy smoker with a persistent cough is noted to have a suspicious lesion on a chest x-ray. The GP messages the practice reception to arrange an urgent appointment with the patient. There is no answer on the patient’s home telephone as he is on holiday. The message to follow up is missed. Two months later the patient presents with shortness of breath and haemoptysis. He is admitted to hospital via MAU and is diagnosed with lung cancer.
Death Any patient safety incident that directly resulted in death A patient is on a repeat prescription for morphine sulphate 10mg twice a day for chronic pain. The patient requests a prescription. In error, a prescription is issued for morphine sulphate 100mg twice a day. The medication is dispensed. The patient’s wife looks after his medicines. She gives her husband 100mg tablets of morphine sulphate. He takes 2 doses over the next day and then his wife is unable to rouse him in the morning. He is admitted to hospital where he has a cardiac arrest and dies.

What happens to the reports?

When patient safety incidents are reported, the data is aggregated and analysed. Expert clinical input and computerised analytical tools are used. This helps understand the frequency and types of patient safety incidents, patterns, trends and underlying contributory factors. This analysis will inform national learning about risks to patient care. It establishes priorities for action. It also establishes work to develop practical solutions to improve patient safety.

Reporting patient safety incidents to NRLS

1. All categories of patient safety incidents should be reported

Many reported incidents are about implementation of care, monitoring, review and medication issues. Many others are about administrative processes. For example, documentation (including records/identification), access, transfer and discharge. Learning from incidents about administrative processes is equally important.

2. GPs, practice nurses, practice managers and all practice staff are able to report to NRLS using this form

In addition to clinical staff, it may be more appropriate for a clinical member of the team to report the incident. This may be due to the nature of the information. Situations when this should happen should be agreed locally at the practice. Other members of the team should be empowered and encouraged to report and share learning from incidents.

3. All levels of harm including “no harm” events where harm has been prevented, should be reported

It is vital prevented or potential incidents which could have caused harm are reported and analysed in the same way as other incidents. They are excellent sources of learning about the barriers and defences the practice has. They show what has worked or preventative actions taken to stop an incident causing harm to a patient.

4. Anonymised aggregated data is used for analysis of trends and themes. All person identifiable information is removed. This includes the names of staff members.

When things go wrong, quick assumptions and routine assignment of blame do not get to the heart of the issue. When a patient safety incident happens, the crucial issue is not “who is to blame for the incident?” but “how and why did it happen”. One of the most important questions is “what is this telling us about the systems in which we work”. Giving a comprehensive description of the incident, as well as detailing what events you believe contributed to its occurrence, can produce learning at a wider level. For example, at CCG or national level. This informs future interventions for safer practices.

When reporting with the new GP specific eform, practices can choose to include their practice name and code. Including this data will enable NRLS to share information with Local Area Teams and the CCG. They can also report entirely in an anonymous manner. NRLS will still analyse the information for themes and trends. This can generate national learning. Person-identifiable information is not required. This includes both patients and staff, and certainly not to apportion blame to any individuals.

5. High reporting is a sign of an open and fair safety culture

An increase in reporting of patient safety incidents is a sign that an open and fair culture exists. It is a sign that staff learn from things that go wrong. Organisations with a culture of high reporting are more likely to have developed proactive reporting and learning. This makes sure the services they provide are safe.

Experience from other sectors, for example aviation, clearly shows as reporting levels rise serious incidents decline ('Seven Steps to Patient Safety'). In acute healthcare, low levels of reporting from an individual trust is recognised as a cause for concern. It warrants further investigation of safety.

Last updated:
29 September 2020