National Reporting and Learning System Research and Development

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