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NPSA Signals

Emerging issues from national review of serious patient safety incidents

Every two months the National Reporting and Learning Service (NRLS) shares key risks emerging from review of serious incidents reported by the NHS.

The NRLS’s Reporting and Learning System (RLS) now holds over 3.5 million patient safety incidents, reported from across the NHS in England and Wales. In this large database, it may be difficult to identify the most pressing issues, given the ‘noise to signals’ ratio. 

The NRLS reviews each reported incident of patient death or serious harm – around 350 every week. These are then prioritised for action, based on evidence from the wider incident database, litigation data and clinical input.

Around 10 a year result in Rapid Response Reports (RRRs) which require actions by trusts to reduce risks to patients. But there is much rich learning over and above those issues that result in RRRs.

Many of these topics are still being explored by the NPSA and other organisations. 

It is really important that organisations continue to report patient safety incidents in the usual way through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.


Issue 8 published February 2012

Latest topics include:

See also RRRs relevant to Emergency Medicine