Learnings from the Pilot Study: National Reporting and Learning System Database to identify Patient Safety trends in Respiratory Medicine

The British Thoracic Society (BTS) Quality Improvement Committee (QIC) focuses on supporting the delivery of the Society’s Quality Improvement Programme. As part of this programme, the QIC reviews and supports data collection activities, including topics that pertain to patient safety. As part of the 2023-2025 Committee Strategy, interest was raised in testing whether choosing respiratory-specific search terms in the National Reporting and Learning System (NRLS) data was a viable and useful way to identify opportunities for quality improvement in respiratory care. A pilot was planned and implemented for this purpose.

The NRLS is a confidential database of patient safety incidents reported by healthcare organisations or individuals in England. Information submitted to the database can be requested and analysed in order to identify and minimise potential risks to patients.

Given that there is not currently a distinct way of identifying incidents related to respiratory-specific practice, two areas were chosen for investigation: non-invasive ventilation (NIV) and pneumonia. The pilot investigated the number of mentions of these and related terms and applied thematic analysis to identify any trends. A report was created summarising these trends and other outcomes, subsequently outlining best practice and key areas for improvements, as well as recommendations for hospitals to prevent the most frequently reported incidents.

The pilot project found both advantages and disadvantages of using the NRLS dataset to identify patient safety issues. Advantages included access to a large and diverse dataset that included both quantitative and qualitative data. Limitations primarily centred around difficulties in segmenting data into respiratory-specific events.

Ultimately, the pilot found that using NRLS data for identifying patient safety incidents in respiratory medicine is both feasible and useful. BTS would like to encourage the respiratory community to consider further areas where using this data could be beneficial.

On the report, Dr Mark Juniper, Chair of the BTS Quality Improvement Committee, said,

“This was a great opportunity to learn from patient safety reports from the whole country. Some safety events don't occur frequently enough in an individual hospital to get the attention they deserve. We hope that by highlighting some of these and making recommendations, we can help improve the care of respiratory patients in all settings.”

Read the report here