Recommendation 12

Reporting of incidents

Accepted
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.

The government agreed in its response to the inquiry, Patients First and Foremost, that clear accountability for trust boards is essential so that they understand their responsibilities to patients. This includes a regard to patient safety and fundamental standards.

The Care Quality Commission will develop and inspect against the fundamental standards, of which patient safety will be an essential component. NHS England is committed to working with the Care Quality Commission on developing a shared and agreed approach to measuring safety in the NHS (both for regulatory and improvement purposes) and is actively in discussion with the Care Quality Commission on the patient safety measures, including incident reporting, best suited for use in their surveillance model and how NHS England can contribute to this.

‘Patient safety incidents reported’ is also one of the overarching indicators in domain 5 of the NHS Outcomes Framework and describes the readiness of the NHS to report harm and learn from it. Therefore, it is important that staff receive feedback on any concerns they raise about patient safety including via local incident reporting systems. At a national level, NHS England will re-commission the national reporting and learning system to improve its functionality, uses and benefits. This will also aim to strengthen reporting and learning from the most serious incidents, with quicker notification and feedback of the relevant lessons learnt, and with more efficient mechanisms for distributing incident reports to relevant organisations, such as clinical commissioning groups, the Care Quality Commission, Monitor, the National Trust Development Authority and the Medicines and Healthcare Products Regulatory Agency.

 

Update

Patient safety incident reporting is a key part of patient safety improvement. 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.

On 24 June, 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 from existing data sources, including the Care Quality Commission Intelligent Monitoring data, 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 has been progressed by NHS England with the development of a long list of options for the new system based on input from a wide range of stakeholders and experts. The options are now being appraised in terms of technical feasibility, deliverability and operational impact and will be utilised to support the strategic business case. The procurement of the new system will then progress in the 2015/16 financial year, subject to approvals.

The Care Quality Commission is giving greater prominence to safety alerts in its revised surveillance model. The Care Quality Commission’s NHS acute Intelligent Monitoring system includes a composite indicator around completion of safety alerts which contributes to providers’ risk scores. Discussions are taking place as to whether this can be implemented for the other sectors the Care Quality Commission regulates.

Providers are expected to retain accountability for implementing patient safety alerts while demonstrating safety improvement and learning in order to give safety alerts more prominence in the inspection model.