NHS England has recently launched their reporting system for patient safety events in General Practice. The form is simple and can be accessed here: https://report.nrls.nhs.uk/GP_eForm

Identification of mishaps and near misses are central to improving quality so a central reporting system is an important step.

But will it work?

Open reporting of adverse events is engrained in many fields such as the aviation industry but not in medicine. We have some powerful disincentives to reporting in addition to the need of a change in culture. Barach and Small recognised that, in order to incentivise reporting, it is important have a system that maximises confidentiality, has an emphasis on bidirectional information flow and improvement in local processes.

Another important distinction in reporting is between near misses and actual adverse events. Including near misses will increase the number and diversity of reports allowing for more detailed quantitative analysis and breaks down some of the barriers of reporting for adverse events.

In order for this culture change to succeed it is not only all members of the clinical team who need to be open to ways in which we can improve and spend the time to reflect and report. We will need to see that the data is truly, continuously and sensitively used to provide useful specific timely feedback.

I would like to see not only reporting but also feedback from relevant analyses integrated into CPD solutions so, despite our busy days, we can truly maximise learning opportunities from these educationally rich learning events. Surely it would be our greatest failing if we do not do this.