National Patient Safety Agency functions

Accepted in principle.
All serious incidents involving severe harm and death reported by individuals to via the on-line e-form, or any route, are routinely shared with the Care Quality Commission on a weekly basis. The Care Quality Commission also receives all incident reports to the National Reporting and Learning System on a weekly basis, regardless of the seriousness of the incident or the source of the report. The Care Quality Commission also has direct access to the national Serious Incident reporting system, STEIS (the Strategic Executive Information System), which is used by commissioners and providers to report and manage serious incidents in NHS-funded care. It is therefore able to view all the information submitted to that system regarding Serious Incidents as well.
The Government does not support the view at this stage that there should be a mandatory reporting system for all incidents however, as set out in recommendation 98, NHS England and the Care Quality Commission are committed to working together to develop a shared and agreed approach to measuring safety in the NHS, both for regulatory and improvement purposes. NHS England and the Care Quality Commission are working together to agree a set of patient safety measures, including all incidents reported. The Care Quality Commission will also be reviewing its approach to looking at serious untoward incidents as part of our pre- inspection activity.

Please see response to recommendations 98 and 99.

The designation of 'serious incident' has been abolished in the NHS. The Learn from Patient Safety Events (LFPSE) service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare.

As set out in the update to recommendation 98, NHS England and the Care Quality Commission have co-developed a new set of indicators that are used in the Care Quality Commission’s Intelligent Monitoring system that flag as at risk or at elevated risk all organisations demonstrating any of the following:
• potential under-reporting of patient safety incidents as suggested by organisations who are reporting significantly fewer patient safety incidents than other organisations
• potential under-reporting of patient safety incidents causing death and severe harm as suggested by organisations who are reporting significantly fewer of these kinds of incidents than other organisations
• potential under-reporting of patient safety incidents involving no harm as suggested by organisations who report a significantly higher proportion of incidents involving harm than other organisations
• poor organisational commitment to monthly reporting of incidents to the National Reporting and Learning System, as demonstrated by reporting 3 months or less out of six; or
• where a hospital has significantly lower scores than other organisations in relation to the percentage of staff who report their organisations’ procedures and responses to incident reports are fair and effective via the NHS Staff Survey.

This recommendation was accepted by the Government in principle.

In the January 2014 Hard Truths report, the Government said that all serious incidents involving severe harm and death reported by individuals were routinely shared with the Care Quality Commission on a weekly basis and that the Care Quality received all incident reports to National Learning and Reporting System on weekly basis, regardless of the seriousness of incident.

The Government rejected the view that there should be a mandatory reporting system.

In the February 2015 Culture Change report, the Government also said that the Care Quality Commissions new Intelligent Monitoring System assessed the pattern of incident reporting to the National Reporting and Learning System by flagging organisations which demonstrated potential under-reporting of safety incidents or poor organisational commitment to monthly reporting of incidents.