Recommendation 99

National and Reporting and Learning System information

Accepted in principle
The reporting system should be developed to make more information available from this source.  Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.

This recommendation refers to the reporting of patient safety incidents by individuals as opposed to via the ‘standard’ route of uploading incident reports from organisations’ local risk management systems. It is predicated on the view that these reports may contain more information than those reported via an organisation’s own reporting system (the ‘corporate version’) and are of use where individuals feel unable to report an incident to their own organisation.

An online incident reporting e-form that can be used by individual staff, patients and the public to report patient safety incidents directly exists. While staff who use the online e-form form are encouraged to also report the incident to their employer’s local systems, there is no automatic link back to local systems. Therefore there is a risk that by encouraging wider use of reporting routes that avoid local organisations’ own reporting systems, important information about the incident may not reach the organisation concerned. This would severely compromise local learning and improvement. In addition, creating an automatic link may well discourage people from using the e-form if they are concerned about the response of the organisation in question. Taking into account these considerations, NHS England will consider how to make the online e-form more widely available and explore the feasibility of online reports being fed back to trusts at the same time as they are reported to the National Reporting and Learning System. NHS England is reviewing the National Reporting and Learning System in order to redesign and re-commission the system to ensure it is more responsive, easier and simpler to use and makes incident reporting and feedback a more worthwhile activity for users. In particular, NHS England is looking to make sure the reporting portal is more widely known and advertised.

More importantly, NHS England’s programme of work will further encourage a culture in the NHS where staff feel able to report any incident to their own organisation in as full and informative a way as necessary. This together with work being taken forward by the professional regulators in response to recommendation 181, should create a more open and transparent culture and promote a climate of learning to drive improvements in patient safety.

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.

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. 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. Consideration is actively being given to the importance of making incident reporting as easy and widely accessible as possible through direct reports by individuals, including staff and patients. Further development of the e-form as well options to allow access via web and smart phone apps is being considered within the redesign. 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.