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National Patient Safety Agency

Joint report highlights high reporting as better for patient safety

19 June 2008


Trusts that report high levels of patient safety incidents suggest a stronger organisational culture of safety because they take all incidents seriously and link reporting with learning from them says a joint briefing from the NHS Confederation and the National Patient Safety Agency (NPSA) (pdf).


The briefing is based on a workshop with 20 consistently high reporting acute trusts as identified by the NPSA through the National Reporting and Learning System. Figures from the Healthcare Commission back up the findings to show that high reporting trusts scored above average on indicators of staff surveys on safety culture.


High reporting can therefore be a sign of a safe organisation that is keen to identify problems as soon as they occur and put plans in place to make things right.  The briefing identifies five key changes that NHS organisations can do to become a high reporting, high reliability organisation that contribute towards an action plan for boards:


  1. Give feedback to staff – tell staff what difference their reporting makes through regular data presentation and even patient stories or staff newsletter

  2. Focus on learning – the focus must always be on the root cause of the problem and can lead to improvements in other areas.

  3. Engage frontline staff – they are key to getting proper data and must be supported and encouraged to report incidents

  4. Make it easy to report – this could mean using the organisation’ s IT systems but it could also mean attaching forms to drug trolleys so incidents can be reported more quickly

  5. Make reporting matter – high reporting trusts demonstrate strong safety leadership from the board down and reporting data is used in conjunction with other sources to make important decisions.


Commenting on the report, Deputy Policy Director of the NHS Confederation Jo Webber said:


“The findings may well challenge public perceptions of what a safe NHS organisation should look like but the Confederation and the NPSA are clear that open reporting of patient safety incidents should be encouraged across the NHS.


“One of the keys to creating an open culture is to make sure we support staff in highlighting incidents as they occur and show them that their vigilance is rewarded by making changes.


“High reporting does not just help with patient safety, however.  The focus is on finding the root cause of incidents so that problems can be resolved.  In practice this can mean looking again at how teams work, investing in extra training or bringing in new equipment.  We are really pleased to be working with the NPSA on this briefing which highlights how much the wider NHS can learn from high reporting trusts.”


Martin Fletcher, Chief Executive, NPSA, said:


“High reporting is a vital sign of an organisation that takes safety seriously.  We welcome the opportunity to launch this briefing at the NHS Confederation annual conference.  The briefing highlights the many benefits of high incident reporting by trusts in order to quickly identify problems, set safety priorities and direct efforts to address risks.  Our ambition is to encourage more trusts to increase their levels of incident reporting so we can help the NHS understand why things go wrong and how to stop them happening again.”




Notes for Editors


  1. The NHS Confederation represents more than 95% of the organisations that make up the NHS. Its members include the majority of NHS acute trusts, ambulance trusts, foundation trusts, mental health trusts, primary care trusts, special health authorities and strategic health authorities in England; trusts and local health boards in Wales; and health and social service trusts and boards in Northern Ireland.

  2. The National Patient Safety Agency encompasses the National Research Ethics Service, Patient Safety Division and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.

  3. The NHS Confederation annual conference and exhibition 2008, Delivering the future today, is taking place on 18th-20th June at Manchester Central. Registration forms for a free pass to the event – Britain’s most important healthcare conference – will be sent out shortly.

  4. For NHS Confederation media enquiries contact Niall Smith 020 7074 3304 or 07767 770309, Ruth Kennedy 020 7074 3312 or 07884 47 3086, or Ruby Casey-Knight 020 7074 3306 or 07881 957305.  For out of hours media enquiries, please call the Duty Press Officer on 07880 500726.

  5. For NPSA media enquiries contact Amelia Lyons on 020 7927 9580 or Paul Cooney on 020 7927 9351.