NRLS organisation patient safety incident reports: commentary March 2018
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Contents 1. Summary... 2 2. Introduction... 3 3. Incidents reported from 2017... 8 4. Incidents reported as occurring from 2017 10 5. Final remarks... 20 6. Contact us for help... 21 1 > Contents
1. Summary Reporting to the National Reporting and Learning System (NRLS) is largely voluntary, to encourage openness and continual increases in reporting. Increases in the number of incidents reported reflects improved reporting culture and should not be interpreted as a decrease in the safety of the NHS. The number of incidents reported to the NRLS by English NHS organisations has increased between April and September 2017 compared to 2016. This is seen in both the number of incidents reported (3.1% increase) and the number of incidents reported as occurring (4.3% increase). The average (median) time to report incidents nationally was 23 days. This is a small reduction from 25 days compared to 2016. Nationally the overall profile of incident characteristics (incident type, degree of harm, care setting where the incident occurs) remains consistent with April to September 2016. Responsible statistician: Julia Abernethy For queries relating to this document or our statistics, please contact: nhsi.nrls.datarequests@nhs.net 2 > OPSIR workbook commentary
2. Introduction This commentary interprets the data published in the organisation patient safety incident reports (OPSIR) for 2017 for English NHS organisations. OPSIR provides organisation-level data on patient safety incidents for NHS organisations, broken down by cluster. A cluster is a group of organisations that share similar characteristics that may influence the number and type of patients they treat and the range of healthcare services provided. The organisation reporting the patient safety incident determines the cluster we use. This may or may not be the organisation where the incident occurred. We use these clusters for NHS organisations: NHS acute non-specialist trust NHS acute specialist trust NHS mental health trust NHS community trust NHS ambulance trust. Organisations that do not fall within these clusters are not included in OPSIR (see Table 1 for more information). Here we analyse data for the current six-month period being published (ie 2017), rather than by month or year. We make comparisons over time with the same six-month period in the previous year (ie 2016 in this instance) to allow more meaningful interpretation. This is because of known seasonality in reporting patterns and when incidents occur. For example, there are peaks in the number of incidents reported every May and November around the cut-offs for two of our routine data publications. So for example, comparing data for April to June for a given year with July to September for the same year would show a decline in the number of incidents reported, simply because of the peak in reported incidents in May. However, comparing April to June 2016 with April to June 2017 would better reflect whether the number of incidents reported had increased or decreased. 3 > OPSIR workbook commentary
The data and this commentary are part of a range of official statistics on patient safety incidents reported to the National Reporting and Learning System (NRLS). Our other official statistic outputs are: national patient safety incident reports (NaPSIR, previously the quarterly data summaries QDS) monthly summary data on patient safety incident reports. 1 The document should be read alongside the OPSIR data tables. The data contained in OPSIR and NAPSIR differs for the reasons listed in Table 1 below. Therefore the OPSIR and NaPSIR statistics are not comparable and numbers should not be expected to match. Detailed information on how we manage data quality and revisions and corrections to the data is available on the OPSIR webpage. 1 The monthly summary data will shortly be classified as experimental statistics and we are working to the code of practice for these statistics. Further information will become available on our webpages. 4 > OPSIR workbook commentary
Table 1: Main features of NaPSIR, OPSIR and monthly workbooks Feature NaPSIR OPSIR Monthly summaries Purpose To provide a national picture of the reporting of patient safety incidents and of the characteristics of incidents (type, care setting, degree of harm). This dataset forms the basis of the indicator Improving the culture of safety reporting in Domain 5 of the NHS outcomes framework (Treating and caring for people in a safe environment and protecting them from avoidable harm). To provide data on individual organisations reporting and patient safety characteristics. Different NHS organisations provide different services and serve different populations. Therefore, to make comparisons as meaningful as possible, the NRLS groups NHS organisations into clusters of similar organisations.* To provide timely data on reporting to the NRLS to encourage more consistent reporting and support organisations to monitor potential underreporting of incidents. Data is provided by organisation, degree of harm and month of report to the NRLS. Organisations are not grouped into clusters. Dataset type Dynamic Fixed/static Dynamic Dataset used Reported and occurring datasets Reported and occurring Reported dataset datasets Period covered Reported dataset: rolling quarters from October to December 2003 to the most recent quarter available. Occurring dataset: rolling quarters covering the last four available quarters. The most recent six months only A rolling 12-month period covering the preceding 12 complete months of available data. Updated Every six months Every six months Every month Geography/ breakdown All geographical locations, by care setting England, by individual NHS organisation (organised by cluster) England, by individual organisation 5 > OPSIR workbook commentary
Feature NaPSIR OPSIR Monthly summaries Inclusions The following care settings: acute/general mental health service community nursing, medical and therapy service learning disabilities service ambulance service general practice community pharmacy community and general dental service community optometry/ optician service The following organisation types: acute/general hospital mental health service community trusts ambulance service The following organisation types: acute/general hospital mental health service community trusts ambulance service integrated care organisation *Information on clusters is available in or accompanies the relevant publication. Figures for previous quarters may change slightly (figures for four consecutive quarters are given in each workbook for incidents occurring, from Tab 5 onwards) as the NRLS is a dynamic system (and incidents can be reported, or updated, at any time after the event). The reported dataset refers to incidents reported by, or within, a certain period. The occurring dataset refers to incidents occurring by, or within, a certain period. See above for more information. Overview of NRLS data collection and interpretation The NRLS collects data on patient safety incidents in England and Wales. This commentary covers data reported by English organisations; data relating to Wales is available online. Most data is submitted to the NRLS from an NHS organisation s local risk management system. A small number of reports are also submitted using online eforms by individuals and organisations that do not have local risk management systems. More information is available in our accompanying guidance notes. 6 > OPSIR workbook commentary
Many factors affect how NRLS data and statistics are interpreted. Detailed information is available in our accompanying guidance notes and data quality statement; this is a summary of factors: Data reflects incidents reported to the NRLS, not the number of incidents actually occurring in the NHS. There can be a delay between an incident occurring and when it is reported to the NRLS, so we publish data based on the occurring dataset (the date when an incident is reported to have occurred) and the reported data (the date when the incident was reported to the NRLS). For any given period, the number of incidents occurring and incidents reported is unlikely to match. Reporting error and bias affect trends in the number of incidents reported to the NRLS; known sources include: the type of organisations that report to us; the type of incidents reported; changes in policy; seasonality in when incidents are reported and when incidents occur (as detailed above); delays in reporting incidents to us. It is important to consider these factors in interpreting or comparing any NRLS data over time. 7 > OPSIR workbook commentary
3. Incidents reported from 2017 This section analyses incidents reported to the NRLS using the reported dataset. This dataset is used to look at patterns in reporting, such as frequency and timeliness. It contains incidents reported to the NRLS within a specified period. It will include incidents that occurred before April 2017, and may include incidents that occurred a long time before this. This dataset will reflect seasonality in when incidents are reported to the NRLS. Reported number of incidents The number of incidents reported to the NRLS continues to increase. Between April and September 2017, 971,542 incidents were reported from England, 3.1% more than during 2016. Timeliness of reporting incidents We encourage organisations to report their incidents to the NRLS regularly and at least once a month. This is so that the NRLS contains up-to-date and complete information to allow the best learning possible. However, reporting delays are still seen in the NRLS data, and large batches of incidents are often submitted every six months close to the cut-offs for the NaPSIR and OPSIR publications. This causes marked peaks in reporting patterns as discussed above. Chart 1.1 in the NaPSIR data workbook shows seasonality based on the reported dataset for national-level data. Some users report incidents once a full investigation has been completed often a considerable time after the incident occurred and this can also cause delays in reported incidents. We measure the timeliness of reporting as the difference in days between the date the incident was reported to have occurred and the date the incident was reported to the NRLS. The overall reporting timelines nationally are reported as an average (median). 8 > OPSIR workbook commentary
The average (median) time to report for English NHS organisations has decreased from 25 days ( 2016) to 23 days ( 2017). In 2017 this ranged from a minimum of 0 days to a maximum of 37,366 days. The large maximum number of days is caused by the incident date being incorrectly entered, eg as 1917 rather than a more recent and feasible date. We cannot correct these data quality issues because we do not know with certainty the true date that should have been entered. 9 > OPSIR workbook commentary
4. Incidents reported as occurring from April to September 2017 This section analyses incidents using the occurring dataset. This dataset is used to look at patient safety incident characteristics. It contains incidents reported as happening (occurring) in a specific period. The dataset reflects seasonality in when incidents occur. Analysis based on it may be biased by fluctuation in numbers over time due to reporting delays. In this report, analysis includes incidents reported to have occurred between April and September 2017 and reported to the NRLS by 30 November 2017. This cut-off is to allow time for local quality assurance and analysis. The number of incidents reported as occurring for any period will differ from the number of incidents reported in the same period because they capture different data. For example, incidents reported between April and September 2017 will include incidents that occurred in this period and incidents occurring before April 2017 because of known delays in reporting. The number of incidents reported as occurring to the NRLS continues to increase. During 2017, 937,969 incidents were reported as occurring from England. This is 4.3% more than during 2016. The increase in incidents reported as occurring in the same period varies by cluster (Table 2). The greatest increase in incidents reported as occurring was seen among NHS ambulance trusts (9.0%), and the smallest among NHS acute specialist trusts (0.7%). 10 > OPSIR workbook commentary
Table 2: Number and percentage of patient safety incidents reported to the NRLS as occurring; 2016 and 2017 NHS cluster Acute nonspecialist Acute specialist Mental health 2016 2017 Percentage change N % N % over time 673,865 74.9 705,564 75.2 4.7 24,430 2.7 24,612 2.6 0.7 162,954 18.1 167,477 17.9 2.8 Community 32,855 3.7 34,226 3.6 4.2 Ambulance 5,586 0.6 6,090 0.6 9.0 Total 899,690 100 937,969 100 4.3 Incident characteristics When incidents are submitted to the NRLS, users also enter information describing the incident in more detail. For example, we collect information on the type of incident and where it occurred. This helps us learn more about the types of incidents occurring in the NHS and focus our efforts to reduce harm to patients. Key incident characteristics, by cluster, are described below. Degree of harm The degree of harm should describe the actual degree of harm suffered by the patient as a direct result of the patient safety incident. There are five NRLS categories for the degree of harm: no-harm a situation where no harm occurred: either a prevented patient safety incident or a no-harm incident 11 > OPSIR workbook commentary
low harm any unexpected or unintended incident that required extra observation or minor treatment and caused minimal harm to one or more persons moderate harm any unexpected or unintended incident that resulted in further treatment, possible surgical intervention, cancelling of treatment, or transfer to another area, and which caused short-term harm to one or more persons severe harm any unexpected or unintended incident that caused permanent or long-term harm to one or more persons death any unexpected or unintended event that caused the death of one or more persons. The degree of harm helps us learn about the impact of incidents on patients and identify those incidents causing most harm (severe harm and death), to prioritise clinical review of these incidents. Clinical review uses NRLS data to identify new or emerging issues that may need national action, such as a patient safety alert. It is still important that incidents causing all degrees of harm are reported to the NRLS, as this breadth of information is fundamental to improving patient safety. Sometimes reporters give an incident s potential degree of harm instead. For example, the resulting degree of harm is occasionally coded as severe for near miss where no harm resulted as the impact was prevented. This should be considered when interpreting the degree of harm. Most incidents reported by all clusters were reported as no harm or low harm (Table 3). The percentage of no and low-harm incidents ranged from 78.7% (19,365/24,612) in acute specialist trusts to 53.9% (18,454/34,226) in community trusts. The percentage of incidents reported as severe harm or death ranged from 1.4% (83/6,090; severe harm) and 1.0% (n=63; death) in ambulance trusts to 0.2% (43/24,612; severe harm) and 0% (n=12; death) in acute specialist trusts. 12 > OPSIR workbook commentary
Table 3: Reported degree of harm by NHS cluster; incidents reported as occurring from 2017 NHS cluster Reported degree of harm No harm Low Moderate Severe Death Total N % N % N % N % N % N % Acute nonspecialist 547,275 77.6 142,443 20.2 13,364 1.9 1,821 0.3 661 0.1 705,564 100 Acute specialist 19,365 78.7 4,814 19.6 378 1.5 43 0.2 12 0.0 24,612 100 Mental health 109,982 65.7 48,043 28.7 7,708 4.6 532 0.3 1,212 0.7 167,477 100 Community 18,454 53.9 12,939 37.8 2,615 7.6 156 0.5 62 0.2 34,226 100 Ambulance 4,029 66.2 1,685 27.7 230 3.8 83 1.4 63 1.0 6,090 100 13 > OPSIR workbook commentary
The distribution of degree of harm in the current period ( 2017) is broadly consistent with that reported for incidents occurring in 2016. Incident category Incident category is important because it helps us understand if certain types of incident are more common than others, so we can target our learning. Many factors can affect the types of incident reported by different organisations, and this can cause variation within and between clusters. The four most commonly reported incident categories for each cluster in the current and previous period are summarised in tables 4a to 4e. Full detail is available in the OPSIR data tables. In the current period the reported incident category, rank and percentage of the top four incident categories varied by cluster. For example, among acute non-specialist trusts Patient accident was the most common incident category (15.9%; 112,005/705,564). By contrast, among community trusts the most common incident category was Implementation of care and ongoing monitoring/review (37.0%; 12,666/34,226). Table 4a: Reported incident category acute non-specialist cluster; incidents reported as occurring in 2016 and 2017 Incident category April to September 2016 N % N % April to September 2017 % change Patient accident 116,594 17.3 112,005 15.9-3.9 Implementation of care and ongoing monitoring/review Access, admission, transfer, discharge (including missing patient) 91,274 13.5 98,219 13.9 7.6 74,841 11.1 87,721 12.4 17.2 Treatment, procedure 80,014 11.9 83,754 11.9 4.7 All other incident categories 311,142 46.2 323,865 45.9 4.1 Total 673,865 100 705,564 100 4.7 14 > OPSIR workbook commentary
Table 4b: Reported incident category acute specialist cluster; incidents reported as occurring in 2016 and 2017 Incident category 2016 N % N % 2017 % change Medication 4,263 17.4 4,192 17.0-1.7 Treatment, procedure 3,310 13.5 3,705 15.1 11.9 Documentation (including records, identification) Access, admission, transfer, discharge (including missing patient) All other incident categories 3,556 14.6 3,693 15.0 3.9 2,063 8.4 2,319 9.4 12.4 11,238 46.0 10,703 43.5-4.8 Total 24,430 100 24,612 100 0.7 Table 4c: Reported incident category mental health cluster; incidents reported as occurring in 2016 and 2017 Incident category 2016 2017 N % N % % change Self-harming behaviour 35,772 22.0 36,486 21.8 2.0 Patient accident 25,934 15.9 25,338 15.1-2.3 Disruptive, aggressive behaviour Implementation of care and ongoing monitoring/review 23,482 14.4 21,752 13.0-7.4 14,053 8.6 15,766 9.4 12.2 All other incident categories 63,713 39.1 68,135 40.7 6.9 Total 162,954 100 167,477 100 2.8 15 > OPSIR workbook commentary
Table 4d: Reported incident category NHS community cluster; incidents reported as occurring in 2016 and 2017 Incident category 2016 2017 N % N % % change Implementation of care and ongoing monitoring/review 10,863 33.1 12,666 37.0 16.6 Patient accident 5,835 17.8 5,289 15.5-9.4 Medication 3,506 10.7 3,550 10.4 1.3 Access, admission, transfer, discharge (including missing patient) 2,993 9.1 3,225 9.4 7.8 All other incident categories 9,658 29.4 9,496 27.7-1.7 Total 32,855 100 34,226 100 4.2 Table 4e: Reported incident category ambulance cluster; incidents reported as occurring in 2016 and 2017 Incident category Access, admission, transfer, discharge (including missing patient) April to September 2016 N % N % April to September 2017 % change 1,304 23.3 1,322 21.7 1.4 Treatment, procedure 1,009 18.1 931 15.3-7.7 Consent, communication, confidentiality 596 10.7 648 10.6 8.7 Medical device/equipment 497 8.9 646 10.6 30.0 All other incident categories 2,180 39.0 2,543 41.8% 7.2 Total 5,586 100 6,090 100 9.0 16 > OPSIR workbook commentary
Care setting of occurrence Information on the reported care setting of occurrence helps us understand where reported incidents have occurred, as they can be reported by any organisation even if they did not happen in the reporting organisation. The four most commonly reported care settings for each cluster in the current and previous period are summarised in tables 5a to 5e. The reported care setting of occurrence, rank and percentage of the top four care settings varied by cluster. For example, among acute non-specialist trusts acute/general hospital was the most common care setting of occurrence (95.2%; n=671,560), followed by community care settings (4.6%; n=32,274), with the remaining care settings comprising less than 1% of reported care settings, respectively. By contrast, among mental health trusts the most common care setting of occurrence was mental health service (73.4%; n=122,915) followed by community care settings (20.6%; n=34,420), learning disabilities service (4.9%; n=8,199), with acute/general hospital and all other care settings comprising less than 1% of care settings, respectively. Table 5a: Reported care setting of occurrence acute non-specialist cluster; incidents reported as occurring in 2016 and April to September 2017 Care setting of occurrence 2016 2017 N % N % % change Acute/general hospital 642,481 95.3 671,560 95.2 4.5 Community nursing, medical and therapy service (including community hospital) 29,883 4.4 32,274 4.6 8.0 General practice 837 0.1 982 0.1 17.3 Ambulance service 305 0.0 371 0.1 21.6 All other care settings 359 0.1 377 0.1 5.0 Total 673,865 100 705,564 100 4.7 17 > OPSIR workbook commentary
Table 5b: Reported care setting of occurrence acute specialist cluster; incidents reported as occurring in 2016 and April to September 2017 Care setting of occurrence 2016 N % N % 2017 % change Acute/general hospital 23,493 96.2 23,799 96.7 1.3 Mental health service 599 2.5 529 2.1-11.7 Community nursing, medical and therapy service (including community hospital) 244 1.0 204 0.8-16.4 Ambulance service 93 0.4 80 0.3-14.0 All other care settings 1 0.0 0 0.0 N/A Total 24,430 100 24,612 100 0.7 Table 5c: Reported care setting of occurrence mental health cluster; incidents reported as occurring in 2016 and April to September 2017 Care setting of occurrence 2016 N % N % 2017 % change Mental health service 119,452 73.3 122,915 73.4 2.9 Community nursing, medical and therapy service (including community hospital) 32,191 19.8 34,420 20.6 6.9 Learning disabilities service 9,954 6.1 8,199 4.9-17.6 Acute/general hospital 612 0.4 1,007 0.6 64.5 All other care settings 745 0.4 936 0.5 25.6 Total 162,954 100 167,477 100 2.8 18 > OPSIR workbook commentary
Table 5d: Reported care setting of occurrence NHS community cluster; incidents reported as occurring in 2016 and April to September 2017 Care setting of occurrence Community nursing, medical and therapy service (including community hospital) 2016 N % N % 2017 % change 29,562 90.0 30,896 90.3 4.5 Acute/general hospital 1,589 4.8 1,648 4.8 3.7 Mental health service 840 2.6 782 2.3-6.9 General practice 391 1.2 434 1.3 11.0 All other care settings 473 1.4 466 1.3-1.5 Total 32,855 100 34,226 100 4.2 Table 5e: Reported care setting of occurrence ambulance cluster; incidents reported as occurring in 2016 and 2017 Care setting of occurrence 2016 N % N % 2017 % change Ambulance service 5,317 95.2 5,862 96.3 10.3 Acute/general hospital Community nursing, medical and therapy service (including community hospital) General practice 219 3.9 164 2.7-25.1 34 0.6 47 0.8 38.2 15 0.3 15 0.2 0.0 All other care settings 1 0.0 2 0.0 N/A Total 5,586 100 6,090 100 9.0 19 > OPSIR workbook commentary
5. Final remarks The NRLS is a system designed to support learning. The incidents collected reflect what is reported to us and reporting culture. The system is not designed to count the actual number of incidents occurring in the NHS. Therefore the continual increase in incidents reported to the NRLS over time indicates a constantly improving reporting culture. This increase, together with the reduction in the time taken to report incidents, also provides more opportunity for us to learn and reduce the risk of harm to patients. The overall type of incidents being reported to the NRLS remains similar compared to 2016. We rely on the quality and accuracy of information submitted to be able to focus our learning and interventions to reduce harm. We continue to use this information to identify which incidents are clinically reviewed and how we work to improve patient safety. We also encourage all users to review their own patient safety incidents to understand more about their reporting culture and areas where local improvements in safety culture and patient safety can be made. We are currently developing a new data collection system to replace the NRLS. The system will affect the exact type of data we collect, which will result in changes being made to our statistics outputs. More information is available online. We thank all staff, patients and members of the public who have taken the time to report incidents. This information is essential in helping us all improve patient safety and protect our patients from harm. 20 > OPSIR workbook commentary
6. Contact us for help If you have any questions about the NRLS data collection, the published data or your organisation s data please contact the NRLS team: nhsi.nrls.datarequests@nhs.net 21 > OPSIR workbook commentary
Contact us: NHS Improvement Wellington House 133-155 Waterloo Road London SE1 8UG 0300 123 2257 enquiries@improvement.nhs.uk improvement.nhs.uk Follow us on Twitter @NHSImprovement This publication can be made available in a number of other formats on request. NHS Improvement 8 Publication code: CG 50/18