IGHI's Centre for Health Policy host event on the progress of the NRLS Development Programme.

Patient safety experts gathered at the Royal Society of Arts last week at a summit hosted by IGHI’s Centre for Health Policy to hear about the progress of the National Reporting and Learning System (NRLS) Development Programme. The NRLS, which was set up in 2003, is a central database of patient safety incident reports and the aim of the summit was to establish a common understanding of the strengths and limitations of the NRLS and generate new and innovative ideas for the future of incident reporting in patient safety.

Awareness about the true cost of medical errors leading to adverse events was raised in the 1990’s, when clear evidence suggested that large numbers of patients were being harmed by preventable and avoidable medical errors. Reporting and learning from errors is a key strategy for preventing and reducing the incidence of such and this is well established in high-risk industries such as aviation and nuclear power. Acknowledging this approach, the Chief Medical Officer published An Organisation with a Memory in 2000; establishing the National Patient Safety Agency (NPSA) and the National Reporting and Learning System (NRLS).

In June 2012, the key functions and expertise for patient safety developed by the NPSA – including the NRLS – transferred to NHS England. This was to ensure that patient safety remains at the heart of the NHS agenda and builds on the learning and expertise developed by the NPSA. NHS England commissioned Imperial’s Centre for Health Policy to deliver a two-year development programme to improve the NRLS and its impact on reducing harm. This is to ensure it is able to meet the needs of a changing NHS and continues to build the evidence, knowledge and information to improve the safety of patient care.

The summit heard from speakers including Professor the Lord Darzi of Denham - Director of the Centre for Health Policy and IGHI, Professor Sir Liam Donaldson – Professor of Health Policy at Imperial, Ryan Callahan – Policy Fellow in the Centre for Health Policy, Professor Nick Black of the London School of Hygiene and Tropical Medicine, Dr Mike Durkin - National Director of Patient Safety at NHS England, Professor Bill Runciman – Professor of Patient Safety at the University of South Australia, and Egbert Schillings – CEO of the Qatar Foundation’s World Innovation Summit for Health (WISH).

Professor the Lord Darzi Lord Darzi, Director of the Centre for Health Policy and IGHI said “The NRLS is a rich source of information on patient safety and since its inception eleven years ago, it has already received over nine million incident reports. It is therefore vital that we collaborate in order to find out what works and what doesn’t and how do we improve the system in which the learning from these reports will have an impact on patient safety for generations to come”.

Dr Mike Durkin, Director of Patient Safety at NHS England said “The NRLS is one of the jewels of our NHS and is a shining example to other healthcare systems, but it is not flawless and we need to do everything we can to improve it. There is real power in working with partner organisations and collaborating internationally to identify the best solutions from across the globe and by doing this, we can ensure the NRLS continues to evolve and remains the world’s most comprehensive and effective patient safety incident reporting system.

Sir Liam Donaldson said: “Collecting the right data, analysing it well and acting on the findings can save lives. The NRLS has still to realise its full potential but it remains at the heart of the movement to create a safer NHS