Learning from patient safety incidents


We explain why recording patient safety incidents is important for learning and how to report these incidents. You can also find out how many incidents were recorded and how we use them to support healthcare providers to improve patient safety.

Due to current operational pressures we are temporarily unlikely to process new or outstanding data requests for NRLS or Never Events data. Please check back here for further updates.

Looking for content from the old National Patient Safety Agency (NPSA) website?

The National Patient Safety Agency (NPSA) website has now been archived. Past NPSA alerts and guidance remain available on the archived website but please use these materials with caution. 

The national NHS patient safety team is now part of NHS Improvement. Details of our current reporting and alerting functions can be found below.

Please note: NPSA alerts were only updated to reflect changes in current safety knowledge or clinical care until the point their ‘action compete' date was reached. Some of these ‘action complete' dates for NPSA alerts, safety notices and rapid response reports were over 15 years ago. No NPSA publications have been updated since the closure of the agency in 2012, with the exception of key actions still relevant to the Never Events policy and framework.

Recording incidents protects patients from harm and saves lives

When things go wrong in care, it is vital incidents are recorded to ensure learning can take place. By learning, we mean people working out what has gone wrong and why it has gone wrong, so that effective and sustainable actions are then taken locally to reduce the risk of similar incidents occurring again.

We manage and operate the National Reporting and Learning System (NRLS), which is the world’s largest and most comprehensive patient safety incident reporting system and receives over two million reports each year.

This national system receives incident reports via healthcare organisations’ own local risk management systems where people are encouraged to record details of incidents to support local learning. A small proportion of incidents are also recorded directly on the NRLS, usually where people don't have a local risk management system to record incidents.

How we use information submitted to the NRLS

We use incidents recorded in the NRLS to support learning and improvement at a national level.

Reviewing and analysing these incidents gives us a greater understanding of national priorities for safety improvement. It also helps us identify emerging risks and issues that might not be recognised locally and could merit national action.

The national action we take includes issuing patient safety alerts to raise awareness of a particular risk and to support providers across the NHS to prevent it.

Two-minute video outlining the importance of reporting patient safety incidents to the National Reporting and Learning System.

While patient safety alerts have always been the visible flagship of the process, we also work with our regulatory, clinical and industry partners to address issues identified through incident reports.

Our patient safety review and response reports contain case studies and further explanation on how we do this.

Data on patient safety incidents reported to the NRLS

Every six months we publish official statistics on patient safety incidents recorded on the NRLS.

This usually happens in March and September. Data is published in two formats:

National data on patient safety incident reports: provides a national overview of patterns and trends in the incidents recorded on the NRLS

Monthly data on patient safety incident reports: provides rolling monthly data by organisation on the number of incidents reported to the NRLS in the previous 12 months.

How NRLS data should be used

We want to help all users of NRLS data to understand and use it appropriately. This is important not only for accurate interpretation, but to ensure we continue to encourage improvements in identifying and sharing information about patient safety incidents.

If you use NRLS data, then you should follow our data principles.

Report a patient safety incident

Both healthcare staff and the general public are encouraged to report patient safety incidents, whether they result in harm or not. Find out how to report a patient safety incident.

Development of the Patient Safety Incident Management System (DPSIMS)

We're working to design and deliver a successor to the NRLS and STEIS (the Strategic Executive Information System) through the DPSIMS project.

The project will develop a new system to better support the NHS to learn about what goes wrong in healthcare, and provide learning resources to support safety improvement.

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