NRLS: Patient Safety Incident Reporting and Learning

Responding appropriately when incidents occur in healthcare is a key part of the way the NHS can continuously improve the safety of patients. At general practice level, having systems in place to effectively report and manage patient safety incidents and significant events is essential. This supports clinicians and practice teams to learn about the underlying systems factors and changes that can be made at local level to keep patients safe from avoidable harm.

In practices

All GP practices should have in place clinical governance systems, policies and processes that will assist with recording when issues or incidents have occurred during delivery of patient care.

Patient Safety Incidents are defined as: “Any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care”.  

National system

The National Reporting and Learning System (NRLS) is the NHS national database of patient safety incidents. The reports that it contains are used to identify key themes and trends and enable action to be taken at a national level to prevent similar incidents from occurring. These actions are cascaded to general practice via their local NHS England subregion as patient safety alerts.

Reporting incidents to the central national system helps protect patients from avoidable harm by increasing opportunities for the NHS to learn when things go wrong.

Reporting a Patient Safety Incident

A new e-form, has been specifically designed to make it quick and easy for general practice staff to submit patient safety incident reports to the NRLS.

All patient safety incidents (clinical and non-clinical) should be reported where a patient was harmed or could have potentially been harmed. This includes near misses and incidents where there is a beneficial outcome, for example, where appropriate barriers and defences prevented an incident from occurring. Reporting to the NRLS using the GP e-form can also support local learning as it provides the option to share your report with the clinical commissioning group.