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CQC Essentials: Reporting patient safety incidents to the National Reporting and Learning System (NRLS) for GP practices

The CQC will want to see evidence of how practice identify safety issues, record incidents and near misses and how they report and respond to these incidents during an inspection. This aritcle explains exactly what should be reported to the NRLS and how this information is used.

This article relates to the CQC key question: Is your practice safe? 

In CQC inspections of GP practices, one of the key questions is whether practices are providing safe care. As part of this we look at how practices:

  • identify safety issues,
  • record safety incidents, concerns and near misses, and
  • report and respond to these internally and externally (where appropriate).

So, during an inspection, we look at the practice’s processes and systems to monitor patient safety through reporting patient safety incidents and the practice’s learning from these incidents and significant events.

This article provides some information about reporting patient safety incidents to the National Reporting and Learning System (NRLS). NRLS has introduced a referral e-form and this will allow the learning to be used as part of the practice’s significant event analysis programme.

All providers registered with CQC, including GP practices, are required to notify us about certain incidents.

What is the NRLS?

NRLS enables patient safety incident reports to be submitted to a national database. It was designed by the National Patient Safety Agency based on international experience and best practice: it is the most comprehensive of its kind in the world, receiving over 1.5 million incident reports (NLRS data) from healthcare professionals in 2013 alone. 

This provides the opportunity to ensure that the learning gained from the experience of a patient in one part of the country is used to reduce the risk of something similar occurring elsewhere.

How to report a patient safety incident to the NRLS

Patient safety incidents can be reported via local reporting management systems or directly to NRLS via an electronic reporting form (eForm). NHS England has commissioned a new general practice specific eform

This eform contains enhanced features to enable quick and easy completion together with an associated Continuing Professional Development / Significant Event Analysis reflective template to enable rapid documentation of learning and impact for CPD, Appraisal and Revalidation.

What should be reported?

All patient safety incidents should be reported through NRLS. A patient safety incident can be defined as any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare.

All levels of harm, defined below, should be reported even if no actual harm to the patient has occurred. 

Term Definition Clinical example

No harm

 

Any patient safety incident that did not result in harm or injury or that had the potential to cause harm but was prevented, resulting in no harm (near miss)

A GP prescribes the twice the recommended dose of a new drug, which the local community pharmacist picks up when dispensing the prescription.

Low harm

Any patient safety incident that required extra observation or minor treatment

A patient’s home visit is missed; the patient has cellulitis of the right leg; this was picked up the following day resulting in the GP deciding to prescribe I.V. rather than oral antibiotics which need to be delivered by community frailty team.

Moderate harm

Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm

Continuing treatment with warfarin without monitoring INR for 6 weeks. The patient had an upper GI bleed and was admitted to hospital for 5 days for monitoring and follow-up. It was noted on admission that the INR was 7.

Severe harm

Any patient safety incident that appears to have resulted in permanent harm.

A patient who is a heavy smoker with a persistent cough is noted to have a suspicious lesion on a chest x-ray. The GP messages the practice reception to arrange an urgent appointment with the patient, although there is no answer on the patient’s home telephone as he is on holiday. The message to follow up is missed. Two months later the patient presents with shortness of breath and haemoptysis. He is admitted to hospital via MAU and is diagnosed with lung cancer.

Death

Any patient safety incident that directly resulted in death

A patient is on a repeat prescription for morphine sulphate 10mg twice a day for chronic pain. The patient requests a prescription and, in error, a prescription is issued for morphine sulphate 100mg twice a day. The medication is dispensed and the patient’s wife, who looks after his medicines, gives her husband 100mg tablets of morphine sulphate. He takes 2 doses over the next day and then his wife is unable to rouse him in the morning. He is admitted to hospital where he has a cardiac arrest and dies.

What happens to the reports?

When patient safety incidents are reported, the data is aggregated and analysed with expert clinical input and computerised analytical tools to help understand the frequency and types of patient safety incidents, patterns, trends and underlying contributory factors. This analysis will inform national learning about risks to patient care, establish priorities for action and work to develop practical solutions to improve patient safety.

Five myths regarding reporting patient safety incidents to NRLS:

Myth 1:

Only patient safety incidents of a clinical nature should be reported

Fact: All categories of patient safety incidents should be reported

Although a large number of reported incidents relate to the implementation of care, monitoring and or review and medication related issues, a significant number of reports also relate to administrative processes such as documentation (including records/identification), access, administration, transfer and discharge. The learning from incidents involving administrative processes is equally important.

Myth 2:

Only GPs can report to NRLS using the new general practice specific eform

Fact: GPs, practice nurses, practice managers and all practice staff are able to report to NRLS using this form

In addition to clinical staff, other members of the practice team should be encouraged and empowered to report and share learning from patient safety incidents. For some incidents, it may be more appropriate for a clinical member of the team to report the incident due to the nature of the information, situations when this should occur should be agreed locally within the practice.

Myth 3:

Only incidents that have resulted in actual harm to a patient should be reported

Fact: All levels of harm including 'no harm' events where harm has been prevented, should be reported

It is vital that prevented or potential incidents which could have caused harm are reported and analysed in the same way as other incidents. These are excellent sources of learning about the barriers and defences the practice has in place that have worked, or the actions taken to prevent an incident from causing harm to a patient.

Myth 4:

Reports will be used for performance review of individuals and to apportion blame

Fact: Anonymised aggregated data is used for analysis of trends and themes and all person identifiable information is removed, this includes the names of staff members

When things go wrong it is tempting to blame human error.  However, quick assumptions and routine assignment of blame do not get to the heart of the issue. When a patient safety incident occurs the crucial issue is not 'who is to blame for the incident?' but 'how and why did it occur'.

One of the most important questions to consider is 'what is this telling us about the systems in which we work'. Providing a comprehensive description of the incident, as well as detailing what events you believe contributed to its occurrence, can generate learning at a wider (i.e. CCG, national level) that informs future interventions for safer practices.

When reporting using the new GP specific eform, practices can chose to include their practice name and code. Including this data will enable NRLS to share information with local area teams and the CCG. However, a practice can also choose not to include their practice name or code and report entirely in an anonymous manner.

NRLS will still analyse the information for themes and trends to generate national learning. The purpose of reporting is to learn from incidents to prevent similar incidents occurring, so person-identifiable information is not required (this includes both patients and staff), and certainly not to apportion blame to any individuals.

Myth 5:

High levels of reporting will make the practice 'look bad'

Fact: High reporting is a sign of an open and fair safety culture

An increase in reporting of patient safety incidents is a sign that an open and fair culture exists where staff learn from things that go wrong. Organisations with a culture of high reporting are more likely to have developed proactive reporting and learning to ensure the services they provide are safe.

The experience from other sectors, such as the aviation industry, shows clearly that as reporting levels rise the number of serious incidents begins to decline ('Seven Steps to Patient Safety'). In fact, in the acute healthcare sector, low levels of reporting from an individual trust is recognised as a cause for concern and warrants further investigation of safety.

  • Professor Nigel Sparrow is senior national GP advisor and responsible officer at the CQC

More CQC resources

Picture: iStock

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