Final Report > Chapter 26: The Safety of Care > Creating a culture of safety > A national reporting system

A national reporting system

20 We fully support the principles behind the recommendation of the CMO's expert group and reflected now in the creation of the National Patient Safety Agency that there be a national system for reporting adverse healthcare events and certain specified near misses. Assuming such a system could be made to work, we have no doubt that it would provide an excellent means for identifying patterns of behaviour, for learning and for disseminating lessons throughout the NHS. We make the following comments and suggestions regarding the proposed new national reporting system:

• The national system must be rooted in sound, standardised local reporting systems. There should be clear protocols as to the categories of information which must be forwarded to a national database. It is vital to have good reporting systems locally, so that an event or near miss can be understood in the circumstances in which it arose, and appropriate action taken. It is no less important to have a first-class national system, because of the need to identify patterns, and to share lessons quickly and effectively throughout the NHS. The national and local systems are interdependent and mutually supportive.
• We believe that the national database would be best managed by an independent organisation, outside the NHS and the DoH. This would ensure that a high degree of confidence would be placed in the system by the public; they would see that it was outside the ambit of political influence or control. The managers of the national database should be required to publish summary reports on patterns of adverse events and near misses at least every quarter (and, if necessary, monthly) together with any proposed remedial action.
• To prevent the system's becoming bureaucratic and preoccupied with definitions of what constitutes an `adverse event' or a `near miss', we propose the adoption of the more inclusive term, `sentinel event'. This has been defined as `any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof'. [23] The phrase `or the risk thereof' includes any variation in procedure, a recurrence of which would carry a significant chance of a serious adverse outcome. We endorse the principles reflected in this definition but accept that it may require further refinement. We use the term `sentinel event', as understood here, for the remainder of this chapter.
• The national reporting system should operate broadly in the following manner. It should receive its information from trusts. It should indicate those categories of sentinel event as regards which it requires to be informed, for example, failures in equipment or medication errors. The national system should also make provision for recording information from individual healthcare professionals who, for whatever reason, do not feel confident in informing their local trust. The opportunity should exist to report a sentinel event in confidence. In any case where the safety of patients is in question, those who manage the national reporting system must inform the trust concerned. There must be guarantees in place to ensure that no disciplinary or discriminatory action may be taken against the relevant healthcare professional for the act of reporting. To the extent that a disclosure of such information by a healthcare professional to the national reporting system could not correctly be said to come within the Public Interest Disclosure Act, the Act should be amended. [24]
• The NHS has the unique advantage of being a single organisation with one headquarters. Once a good reporting system is put in place, there is every chance that it will be able to identify and disseminate the lessons to be derived from a particular sentinel event. What is needed is the will to make this happen, the acknowledgement that safety really does matter and, crucially, the resources to put in place good, efficient, standardised and accessible systems for reporting.

Footnotes

[23] Seminar 6. The term `sentinel event', and this definition, were drawn to our attention by the Royal College of Nursing; the term is widely used in the USA by the Joint Commission for the Accreditation of Healthcare Organisations

[24] Or, perhaps more simply, the Secretary of State should, by order under s.43F of the PID Act designate to whom, including the National Patient Safety Agency, disclosure in respect of patients' safety may be made. We deal later with healthcare professionals' reporting to local systems