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Safe practice compromising safe practice?

We would like to update readers on recent developments with the National Patient Safety Agency (NPSA) National Reporting and Learning System (NRLS) since the publication of Catchpole et al.’s paper ‘Safety in Anaesthesia’ [1]. Since ‘Safety First’, a review of the patient safety culture in the NHS, was published in December 2006 [2], the NPSA has been undertaking a considerable amount of work to ensure that the quality of data received into the NRLS is improved. This includes ensuring that the NPSA are rapidly notified of the more severe incidents so they are in a position to respond promptly as appropriate. As part of this initiative the NPSA is interested in working with professional bodies to develop speciality specific reporting systems. For several years the specialty of anaesthesia has been very interested in developing a national critical incident reporting system which allows national shared learning in anaesthesia based on completion of standardised critical incident report forms. To date, although local reporting is taking place, the opportunity had not been available for this to fully develop. A joint initiative is now underway between NPSA, The Royal College of Anaesthestists (RCA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) to develop a speciality specific reporting system for anaesthesia which integrates the more specific taxonomies and classification systems required by anaesthetists with the NRLS. The e-form which has been developed for reporting uses a mixture of free text, key words and drop down menus to describe the incident. It can categorise the incident in up to three different incident types and includes specific detail of equipment and medication involved in the incident. The first phase of this project has focused on anaesthetic incidents occurring during the surgical pathway. The second phase will be extended into critical care and acute ⁄ chronic pain management after consultation with appropriate specialist societies. Once an incident form has been completed, as well as being sent to the NPSA for inclusion into the NRLS, it can also be saved by the department for local learning. It is anticipated that the development of speciality specific reporting will encourage anaesthetists to report and so increase the number of reports currently received into the NRLS. This system will provide RCA and AAGBI with access to the data so that, in conjunction with the NPSA, they will have a pro-active role in analysis and subsequent dissemination of information, improving learning and patient safety on a national basis. A joint ‘safe anaesthesia liaison group’ is currently being established to take this forward. Improvements in reporting will also positively impact on the quality of information that the NPSA is able to feedback to NHS organisations for clinical governance purposes. This reporting system is being piloted in 12 trusts in England and Wales. The pilot has been evaluated in September 2008 with a view to full roll out at the end of the year.