One year on

NRLS Research and Development.

by Kelsey Flott & Erik Mayer

A year on from the publication of NRLS Research and Development, building an improved model for learning from incidents has been a top priority across the Patient Safety Translational Research Centre (PSTRC) and the Big Data and Analytical Unit (BDAU). Researchers across our centres have been working in close collaboration with leaders at Imperial College Healthcare Trust (ICHT) to design evidence-based, practical solutions that work in the NHS.

As the report established, there are many barriers to incident reporting in the NHS, and many more to effective learning. Staff feel burdened by cumbersome reporting platforms, and have little inclination to report when they hear no feedback and see no changes. These problems frustrate staff at all levels of NHS organisations, complicate attempts towards shared learning and, most critically, undermine progress towards safer care.

We have taken a multi-pronged approach to improve this situation. Firstly, we have created a dedicated stream of analytical work to understand existing incident reports so that we can use them in a more meaningful way. This involves advanced network analysis to glean information about incidents’ contributing factors from available incident data. Secondly, we have built on the emerging idea of a new platform for incident reporting, outlined in last year’s report. This is a considerable endeavour considering it not only involves changing practice, it also requires a collaborative team including software/app designers, academic researchers, organisational managers, clinicians, patients and a considerable amount of technical input to ensure secure data storage.

The platform outlined in NRLS Research and Development is called CareReport and it is intended to provide a user-friendly incident reporting interface while also generating meaningful feedback and data for organisational improvement. The CareReport project is now at an exciting time in its development as it is being tested with clinicians in preparation for a full-scale trial. We are working with areas within ICHT that have historically had low rates of reporting, and those that are generally interested to improve the information they have for safety learning. Researchers will be taking their lead from ICHT managers and clinicians to ensure the platform works for staff and accounts for their preferences and obligations. One of the core features of CareReport is that it is flexible. While there are regulatory standards around what type of information an incident reporting system needs to capture, we also recognise that systems need modifications to meet the needs of particular services and staff groups. The scope for such platform customization, as included in CareReport, should be one step towards making the reporting process more palatable for staff.

Incident reporting can feel like a tedious, blaming task. However, our research has demonstrated that staff are eager to learn from incidents and would welcome more feedback and insight into how to prevent them. This sentiment is echoed by all of our colleagues at ICHT. The enthusiasm of ICHT staff, combined with the research, design and analytic capabilities across our centres form a solid baseline for devising a more useful incident reporting platform.

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