This report presents the findings of the NRLS Research
and Development Programme conducted by the
Patient Safety Translational Research Centre (PSTRC)
and the Centre for Health Policy (CHP) at Imperial
College London.
It sets out the current state of affairs regarding
patient safety incident reporting in the NHS, and
specifies where the most pressing areas of concerns are,
including thorough descriptions of the various incident
reporting systems used in the NHS today. Furthermore it
identifies areas for improvement in the overall landscape
of incident reporting, and suggests how systems like the
NRLS can capitalise on developments in technology.
The main body of the report is then devoted to
explaining the findings from the research programme. The
research was divided into four domains, and the report
details the new findings discovered about each of them:
1. Purpose of incident reporting in healthcare
2. User experience with reporting systems
3. Data quality and analysis
4. Effective feedback for learning
Building on these findings, the report moves on to describe
how they can be applied to the next generation of
incident reporting. Specifically, it focuses on a prototype
for a new incident reporting system that incorporates the
improvement ideas generated by the research.
Finally, the report concludes with a description of
an evidence-based framework for evaluating incident
reporting systems and an ‘Achievement Toolkit’ of
ten recommendations for improvements to incident
reporting systems.