The second day of Patient Safety Week was a coming together of experts related to patient safety reporting. We were informed about the research and development work related to the current National Reporting and Learning System and about potential different mechanisms for tackling large national data systems.
The work was undertaken by Imperial Patient Safety Translational Research Centre – funded by NHS England and as part of the NHS National Institute for Health Research.
The report starts with a summary of patient safety information systems in the NHS today:
- The National Reporting and Learning System (NRLS)
- Strategic Executive Information System (STEIS)
- Medicines and Healthcare products Regulatory Agency Yellow Card and medical device reporting (MHRA)
- Care Quality Commission notification database (CQC)
- Public Health England notifications
- NHS Safety Thermometer
- Serious Adverse Blood Reactions and Events (SABRE)
- Serious Hazards of Transfusion Scheme (SHOT)
I can add to this with claims at a national level and other data collection systems related to specialty specific issues including those expected by auditors, researchers, Royal Colleges and so on – AND we have a tendency to forget the multiple hospital level and regional level reporting that is also required.
We were told by Jim Mackey, new CEO of NHS Improvement, that this current ‘patchwork’ of information systems will be reviewed with the aim of reducing duplication of reporting where possible. I can remember trying to do that when we set up the NRLS in 2004 and finding it much more complex that was at first envisaged.
But in the words of Don Berwick – we have to reduce the amount we measure and therefore the amount we report so that it is purposeful and meaningful and is focused on learning and not performance management.
So with the variety of new technologies and intelligence around large data systems that we didn’t have in 2004 I am hoping and hopeful that this endeavour is a success.