Recommendation 98

Mandatory reporting of significant adverse incidents

Accepted in principle
Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.

Reporting of patient safety incidents involving severe harm and death is already mandatory nationally under the Care Quality Commission regulations and these incidents are actively reviewed by NHS England as well as being shared with the Care Quality Commission.

The government’s current policy is not to introduce a mandatory reporting system at this stage however the government does agree there should be a new duty on providers to be candid to patients (as set out in recommendation 174) and more should be done to promote the reporting of all patient safety incidents amongst healthcare professionals (as set out in recommendation 181).

The National Reporting and Learning System  already receives over 1.2 million incident reports a year and NHS England continues to encourage increased reporting from across the health care system. Indicator 5.1 of the NHS Outcomes Framework requires that the NHS continues to increase the numbers of incidents that are reported to the National Reporting and Learning System as this is a good indication of the development of a mature patient safety culture where organisations are open about incidents. NHS England will continue to drive the development of the safety culture within the NHS, not least by implementing relevant recommendations from the Berwick report. Organisations should routinely collect, analyse and respond to local measures that serve as indicators of the level of quality and safety of healthcare, including the voices of patients and staff, staffing levels, the reliability of critical processes and other quality metrics.

As stated in recommendation 97, the Chief Inspector of Hospitals’ assessment will include an inspection for patient safety which will inform the ratings of all NHS providers and the Care Quality Commission and NHS England will work closely together to share information, including reported incidents from the National Reporting and Learning System, to support Care Quality Commission’s surveillance and inspection.

Update

As set out in the updated response to recommendation 12, patient safety incident reporting to the National Reporting and Learning System continues to increase year on year. Data published in April 2014 showed that in the six months from April 2013 to September 2013, 725,314 incidents in England were reported to the National Reporting and Learning System, 8.9% more than in the same period in the previous year.

Following close liaison between the Care Quality Commission and NHS England, the Care Quality Commission’s new Intelligent Monitoring system now assesses the patterns of incident reporting to the National Reporting and Learning System by flagging as at risk or at elevated risk all organisations demonstrating any of the following:

  • potential under-reporting of patient safety incidents as suggested by organisations who are reporting significantly fewer patient safety incidents than other organisations
  • potential under-reporting of patient safety incidents causing death and severe harm as suggested by organisations who are reporting significantly fewer of these kinds of incidents than other organisations
  • potential under-reporting of patient safety incidents involving no harm as suggested by organisations who report a significantly higher proportion of incidents involving harm than other organisations
  • poor organisational commitment to monthly reporting of incidents to the National Reporting and Learning System, as demonstrated by reporting 3 months or less out of six; or
  • where a hospital has significantly lower scores than other organisations in relation to the percentage of staff who report their organisations’ procedures and responses to incident reports are fair and effective via the NHS Staff Survey.

On 24 June 2014, NHS England published the results of a new indicator on the NHS Choices website, rating NHS hospitals for their incident reporting. A good reporting culture in an organisation means that the organisation reports patient safety incidents frequently, reports the more serious incidents that occur but also reports many incidents involving low and no harm to patients, because its staff understand that by reporting even these less serious incidents, the organisation can learn and improve. A good reporting culture is also indicated by the staff of a hospital saying they think the organisation has fair and effective procedures when incidents are reported. These aspects of incident reporting have been combined to give a composite rating for each acute hospital’s reporting culture. The rating does not describe whether a hospital is safe, but does provide patients with authoritative and easy to access information on how well developed the organisation’s patient safety incident reporting culture is and will encourage organisations to improve their reporting culture.

Work to re-commission the National Reporting and Learning System is underway in NHS England with ongoing stakeholder and expert engagement being used to inform the design phase. The options development and appraisal will be progressed in Q3 and Q4 of 2014/15 with the revised design confirmed by the end of March 2015, subject to approvals. The procurement of the new system will then progress over the 2015/16 financial year.