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This letter in the BMJ in 2004 from Richard Thomson highlights the difficulty of accurately quantifying patient safety incidents. Thomson writes that data relevant to patient safety should not be presented alone and out of context. He highlights what was the National Patient Safety Agency and the development of a national reporting and learning system to enable healthcare staff to report incidents anonymously.

Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognise or respond to deterioration. The current study from Albutt et al. explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.

In Spring 2021, a new national Patient Safety Incident Management System (PSIMS) will enter its public beta stage. The new system will be phased in to replace the current National Reporting and Learning System (NRLS). Its aim is to maximise the NHS’s ability to learn from when things go wrong. In this, the first in a series of blogs from Lucie Mussett, PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer., PSIMS product owner, Lucie provides an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer.

A new national NHS Learn from patient safety events service (previously called the patient safety incident management system – PSIMS – during development) is in the final stages of development as a central service for the recording and analysis of patient safety events that occur in healthcare. NHS England has now commenced the public beta stage, where some organisations can begin using the system, instead of the NRLS. LFPSE is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors. LFPSE will initially provide two main services: Record a patient safety event – organisations, staff and patients will be able to record the details of patient safety events, contributing to a national NHS wide data source to support learning and improvement. Once local systems are made compatible, larger organisations such as NHS trusts will record patient safety events to the national system via a direct upload from their Local Risk Management System (LRMS). Other organisations, such as primary care providers (see our dedicated primary care LFPSE webpage) can record patient safety events directly via the online recording service. A dedicated service for patients and families to use will be developed. In the meantime patients can continue to record incidents to the NRLS via the existing patient eform. Access data about recorded patient safety events – Providers will be able to access data that has been submitted by their teams, in order to better understand their local recording practices and culture, and to support local safety improvement work.

Sodium nitrite has one licensed indication: as an antidote to cyanide poisoning. The Royal College of Emergency Medicine (RCEM) and National Poisons Information Service (NPIS) guideline recommends that it should be “immediately available in the emergency department”. Sodium nitrite can cause significant side effects and is categorised as ‘highly toxic’. Historically, sodium nitrite 30mg/ml has been an unlicensed product supplied in ampoules by ‘Specials’ manufacturers. However a licensed product, supplied as a vial, has been available since 2016. The National Reporting and Learning System (NRLS) identified two incidents where unlicensed sodium nitrite was inadvertently administered to premature babies instead of sodium bicarbonate 4.2%: one very premature baby died soon after this incident occurred and the other died after a period of neonatal intensive care. Hospitals have been given until 6 November to physically check all wards for the wrong drug and to destroy any unlicensed sodium nitrite supplies. This alert is an action for all acute trusts (children and adult).

This report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.  The report recommends a number of urgent actions to address these risks to patients.

Over the next three years the Development of the Patient Safety Incident Management System (DPSIMS) project will define and deliver the successor to the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (STEIS). The NRLS is more than 13 years old and due for an upgrade, which is why we're working closely with stakeholders to create a system that will provide resources to support safety improvement and help the NHS learn when things go wrong. The new system will: meet both local and national needs in terms of accessibility to both staff and patients/carers integrate with other systems strike a balance of confidentiality and transparency support an open and honest NHS culture devoted to continuous learning and improvement of patient safety

The National Patient Safety Agency (NPSA) issued guidance on preventing delay to follow up for patients with glaucoma [NPSA/2009/RRR004]. This followed evidence of harm to patients with glaucoma suffering visual loss after delays to follow up appointments. This came to light from incidents reported by staff in the NHS relating to glaucoma. This paper provides background information and a checklist for organisations to help implement actions in the accompanying guidance to prevent harm from delayed follow-up appointments for patients with glaucoma. It presents details of incident data and litigation data. This work was supported by an interactive event in March 2009 with input from ophthalmic surgeons (and the Royal College of Ophthalmologists), nurses, service managers and patient representatives. Key recommendations from the report Treating clinicians should ensure that all people with ocular hypertension or suspected or diagnosed glaucoma are monitored within the monitoring intervals outlined in the NICE glaucoma guideline, and none of these monitoring appointments should be delayed or cancelled.

Rolling data updated monthly, to show the number of patient safety incidents reported to the National Reporting and Learning System (NRLS) in the last 12 months.

Reporting to the National Reporting and Learning System (NRLS) is largely voluntary, to encourage openness and continual increases in reporting to facilitate learning from error. Increases in the number of incidents reported reflects an improved reporting culture and should not be interpreted as a decrease in the safety of the NHS. Equally, a decrease cannot be interpreted as an increase in the safety of the NHS. This report covers the early stages of the COVID-19 pandemic in England, from April 2020 through to the end of March 2021, when cases had declined rapidly. The number of incidents reported from April 2020 to March 2021 was 2,109,057, and represent a small decrease of 6.1% compared to April 2019 to March 2020 (2,246,622).

NHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE). 1. Learning from transitioned providers – adopting the LFPSE service in an acute trust Jackson Stubbs from University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust, describes his experience of leading his trust's switch from the NRLS) to the LFPSE service, his top tips, and what to avoid when planning your transition. 2. Learning from transitioned providers – adopting the LFPSE service in a mental health trust The team at Cumbria, Northumberland, Tyne and Wear (CNTW) NHS FT share how they have found the switch from NRLS to the LFPSE service, their key learning points from the process, and where they’d like to see the project go next

Incident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service LFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the NRLS, and all organisations will be expected to transition to this by 30 September 2023. Concerns about the development and implementation of LFPSE Patient Safety Learning welcomes much of the ambition behind the development of the new LFPSE service and its aim of creating a system from all parts of health and social care. However, in recent months staff have raised with us concerns about the development and implementation of this. Many have said they didn’t feel they were being listened to through formal channels and we have supported them in highlighting their concerns with NHS England. Correspondence with NHS England Attached to this article is the following correspondence between Patient Safety Learning and NHS England in relation to these concerns: 27 July 2022 - Email from Patient Safety Learning to NHS England 27 July 2022 – A briefing note attached to the above email 18 August 2022 - Email from NHS England to Patient Safety Learning 18 August 2022 - Response to briefing note questions attached to the above email 7 September 2022 - Email from Patient Safety Learning to NHS England 7 September 2022 - Letter from Helen Hughes to Aidan Fowler attached to the above email 27 September 2022 - Letter from Aidan Fowler to Helen Hughes During this period there have been some positive developments in regard to the concerns raised, such as a decision to increase flexibility for Trusts so that they can now ask their local risk management system vendors to disable ‘outcome’ and ‘risk’ from the Event Types while you are exploring their use, and to help identify the best way forward. Following the correspondence attached here, on the 18 October 2022 it was announced that NHS Trusts had been given an optional six-month extension to the LFPSE service. This is also a step that we welcomed, with one of the key concerns raised with us by staff concerning their organisations implementation readiness for the initial deadline of the 31 March 2023. To improve patient safety, it is vital that we have an effective, easy to use and transparent system for reporting and learning from patient safety incidents, trusted by both patients and staff. A considerable number of the points we have raised with NHS England in the attached correspondence remain yet unresolved. Patient Safety Learning will continue to support staff in raising any further concerns about the implementation of the LFPSE service where this is helpful.