1. National Patient Safety Agency
Working towards a national surveillance system for patient safety The National Reporting and Learning System and the Patient Safety Observatory
Sarah Scobie
Head of Observatory
National Patient Safety Agency UK

2. To cover up is unforgivable To fail to learn is inexcusable
To err is human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson
Chief Medical Officer
England

3. Purpose of the NPSA Special health authority with mandate to:
implement a national reporting system for patient safety incidents
collect and appraise information to promote patient safety
provide advice and guidance and monitor its effectiveness
promote research which contributes to patient safety
report and advise Ministers on matters affecting patient safety
The NPSA role includes….
and the report concentrates on three key areas:
First, it reports on early data from our National Reporting and Learning System
Second it describes how we bring together data from the NRLS and a range of other sources to understand and characterise patient safety issues
Third it gives examples of how data from these sources is of value in helping us to make the NHS safer.

4. Overview The National Reporting and Learning System
The Patient Safety Observatory: what is it and why do we need it?
The Observatory work programme

5. The National Reporting and Learning System (NRLS)
Confidential reporting database
Incidents are reported electronically – 99% come from Local Risk Management System
Analysis of data at national level to
identify trends and patterns
provide feedback for local action
inform NPSA work programmes

6. Number of incidents and reporting trusts

7. Approaches to analysis of NRLS data
Routine monitoring reports
Thematic analysis
Ad hoc analysis
Exploratory
Reviews of selected incidents
Data mining

8. Routine and thematic reports
Trust feedback reports
Quarterly overview
Thematic reports

10. Ad hoc analysis
Requests from NHS clinicians and risk managers, and relating to current NPSA projects
Use of categorical data supplemented by sophisticated text searching tool
Examples during one week:
epidurals, following fatal incident, to inform an NPSA fast track project on epidural infusions
chairs, for an external enquiry
Midwifery and Obstetrics, for Litigation Authority event on maternity risk management
screening tests for Down's Syndrome, following software issue identified in a trust
systemic dermatology treatments
blood glucose monitors, following issue identified by the regulator for medical devices
wrong route administration of oral liquid medicines, to support the preparation of a patient safety alert

11. Systematic review of incidents
Richness of NRLS data in free text descriptions review from clinical perspective adds value
Huge volumes of data – sampling by specialty and incident type
Tools to support robust and consistent review of data supported by guidance decision tree for follow-up action

12. Data-mining Looking for small localised patterns in the data
Pattern-search
Looking for small localised patterns in the data
Able to look through high-dimensional data (categorical and free text)
Able to pick out small unknown patterns that may represent a trend in patient safety
Model building and hypothesis testing

13. Incident data not the only source
Why do we need a PSO?
Incident data not the only source
Systematic surveillance and analysis of NRLS and other data
1) The National Reporting and Learning System is a fundamental source of data to understanding patient safety. However, on its own it does not give the whole picture of what does or could lead to patient harm. This is because incident reporting systems are for example
not comprehensive – there is a gap between what occurs and what is reported
cannot provide some of the detail that can be provided by other reports (e.g. detailed root cause analysis)
Therefore, incident reporting needs to be part of a broader approach to surveillance and monitoring. The findings from incident reporting musty be considered alongside a range of data so that we can build up a fuller picture.
2.) Many agencies are already involved in collecting and using information relevant to patient safety but the information not always used to full potential. The healthcare system as a whole could make better use of data sets to explore safety, even if such existing data collections were designed for different purposes.
The Patient Safe Observatory works with partners from across a whole range of other organisations, that can help us to assess a problem. This might involve
seeing whether other data sets are identifying similar issues,
it might help tell us something additional about incidents identified in the NRLS;
it might be that we need to access the knowledge and understanding of relevant experts, such as Royal Colleges;
or it may be that we need to access relevant patient safety research literature.
3.) Various datasets will help to generate hypotheses, to analyse data and to implement change

14. Settings of incidents reported to the NRLS
Care setting
Total
Percent
Acute/general hospital
441,519
72.2
Mental health service
86,697
14.2
Community nursing, medical and therapy service (including community hospital)
57,029
9.3
Learning disability service
19,534
3.2
General practice
2,636
0.4
Ambulance service
2,356
Community pharmacy
1,373
0.2
Community and general dental service
179
< 0.1
Community optometry/optical service 8
611,331
100.0
Source: Reports in the NRLS database up to 31 March 2006

15. Trend in reporting rates with time since connection to NRLS

16. Patient Safety Research
Other datasets.
Clinical negligence
MHRA
Hospital Episodes
GP Databases
Patient Safety Research
OTHER ORGANISATIONS
Surveillance &
Monitoring
OBSERVATORY
PRIORITISATION
Other confidential
reporting systems
SOLUTIONS
NRLS
EVALUATION
Intelligence
Healthcare Commission
Expert Groups
Patient/Public
DH/Ministers
Interest Groups etc.
NHS Feedback
& Bounceback
R&D
Research
Public/Patient
eForm
PATIENTS/
PUBLIC

17. The Patient Safety Observatory at Work : MRI scanners
NRLS data: 500 reports; 31 related to implants; five pacemakers, one implantable defibrillator, one heart valve and three aneurysm clips went undetected
PSO: Litigation relating to pacemaker/MRI fatality; 200 incidents reported to medical device regulator; local visits:
frontline staff depending on constant vigilance rather than safer systems
Prioritisation process: report to NPSA Board this month

18. PSO at work: collaboration with other organisations
Hospital episode statistics – developing patient safety indicators based on AHRQ
Clinical negligence: NHS Litigation Authority and medical negligence organisations
Safety culture and processes: NHS staff survey

19. Indicators from administrative data
replicate AHRQ analysis for a sub-set of indicators
mapping coding definitions to ICD10/OPCS4
age and sex standardised indicators derived at national and trust level, as per specifications
validation: length of stay and mortality (cases compared with matched controls)
comparison with US results

20. Preliminary results: rates per 1000 discharges
Indicator
England US
Death in low mortality DRGs
0.7
Decubitus ulcer
5.7
24.7
Iatrogenic pneumothorax
0.2
0.8
Infections due to medical care
0.1
2.3
Postoperative hip fracture
0.3
Postoperative sepsis
16.3
11.8
Assisted delivery
45.3
237.8
Unassisted delivery
21.7
86.2
Caesarean delivery
2.0
5.6

21. Preliminary results: excess length of stay (days)*
Indicator
England US
Death in low mortality DRGs -
Decubitus ulcer
+ 11 +4
Iatrogenic pneumothorax +6
Infections due to medical care
+10
Postoperative hip fracture
+ 23 +5
Postoperative sepsis
+ 13
+11
Assisted delivery
+ 0.6
+0.1
Unassisted delivery
+ 0.5
Caesarean delivery
+ 0.2
+0.4
* Cases vs matched controls

22. Patient Safety Observatory - summary
Systematic analysis
No one source of data is sufficient
Collaboration between relevant organisations
Results:
Investigating and reporting back
Better use of existing data
Path to integrated approach to patient safety surveillance

23. Thank you