8th March 2016

The idea that better information could lead to greater learning, and ultimately safer care, is not new.

Organised by the NIHR Imperial PSTRC, the Information and Learning for Patient Safety Conference highlighted recent work in the UK and abroad, including research efforts by the following entities:

We cannot improve what we cannot measure"

Lord Kelvin

The National Reporting and Learning System (NRLS) Research and Development Programme
Incident reporting – the act of systematically recording and reporting details of errors or injuries to patients – is one of the most common tools used to measure patient safety. In 2001, policymakers in the UK created the National Patient Safety Agency (NPSA), which subsequently set up the first national patient safety reporting system – the National Reporting and Learning System (NRLS). The NRLS is designed to collect information on safety incidents to enable analysis and generate learning to improve the state of care. Since its implementation, the NRLS has collected over 10 million incident reports, making it one of the largest patient safety-focused databases in the world.

Although successful in collecting high frequency, low intensity incidents, the quality and utility of the information has yet to achieve its potential. At the Information and Learning for Patient Safety Conference, researchers from the NRLS Research and Development Programme and other experts in the field discussed the barriers to wider incident reporting, lessons derived the NRLS and the research programme, and the future direction of incident reporting systems.

The NRLS Research and Development Programme was a 3 year project funded by NHS England to evaluate the NRLS, explore new techniques for analysing NRLS data, and synthesise practical recommendations for NRLS improvement. This research directly contributed to the development of a prototype for a new, incident reporting platform - which was launched and demonstrated at the March 8th conference - that is meant to encourage greater uptake and provide more useful data to those who need it most. 

The Leading Health Systems Network (LHSN)
Based at Imperial College and in partnership with the World Innovation Summit for Health (WISH), LHSN is a collaborative network of healthcare leaders and organisations dedicated to improving health care delivery by effectively and efficiently using available resources. Throughout 2015 and 2016, the Network has focused on patient safety via the Safer Care Accelerator programme. This programme brings together network members to exchange insights, experiences, and data around patient safety. 

The Commission on Education and Training for Patient Safety
The Commission on Education and Training for Patient Safety was established to review existing interventions and make recommendations to Health Education England and the wider system, setting out its ambition to improve patient safety through education and training. Chaired by Professor Sir Norman Williams, recent past president of the Royal College of Surgeons and vice-chaired by Sir Keith Pearson, Chair of Health Education England – the Commission gathered evidence through focus groups, interviews, regional visits and online surveys; from patients and their families, carers, students and trainees, frontline staff and executives, as well as international experts and national organisations.

The Commission’s report aims to shape the future of education and training for patient safety in the NHS over the next 10 years. The report will outline ambitions, the case for change, what is working well including case studies and where improvements need to be made. The report will be available online soon. For more information, please visit the Commission's website