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Quality improvement informed by a reporting and learning system
  1. Philippa Rees,
  2. Andrew Carson-Stevens,
  3. Huw Williams,
  4. Sukhmeet Panesar,
  5. Adrian Edwards
  1. Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
  1. Correspondence to Dr Andrew Carson-Stevens, Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK; andypcs{at}

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Klaber and Roland1 discuss the value of patient-centred quality improvement (QI) and highlight challenges for identifying meaningful patient-centred outcomes in child health, particularly in community paediatrics. We are currently analysing primary care patient safety incident reports involving children in England and Wales as reported to the National Reporting and Learning System (NRLS).2 Reports from healthcare professionals and patients are collated in this database and can be used to identify opportunities to improve the safety of patient care. The incident reports are initially reported to local health boards through a variety of paper-based or electronic methods, for local learning. Following anonymisation they are uploaded to the NRLS for national learning and in particular can provide a useful lens for understanding the trajectories of rare events that might otherwise be overlooked in isolation at a local level.

A failure in any of the six Institute of Medicine aims of quality—patient safety, effectiveness, efficiency, timeliness, patient centredness and equity—will compromise the ability for patients to receive high quality care.3 Our preliminary analysis of 2347 reports suggests that reporters consider multiple coexisting ‘aims of quality’—not just safety—when describing an incident. This is unsurprising given the complexity of system failures often contributing to patient safety incidents.4 For those seeking to define patient-centred outcomes, a national reporting system can be a useful source of learning to identify the opportunities for intervention.

A Pareto Chart (figure 1) is a QI tool used to visualise the most important issues (often among many) contributing to a suboptimal outcome. Figure 1 demonstrates an analysis of NRLS reports relating to vaccination errors involving children. The key sources of error are readily identifiable and can inform process redesign to minimise future risk to patients. Patient-centred outcomes at a local level suggested by these data might include: the proportion of children receiving an immunisation at the correct time and the proportion of children receiving recommended number of immunisation doses. At a national level, rarer issues such as ambiguous vaccine packaging leading to ‘wrong vaccine’ administration can also be identified.

Figure 1

Pareto Chart characterising paediatric vaccination errors in primary care reported to the National Reporting and Learning System.

Organisations with a strong, blame-free safety culture will generate more data for analysis. If there is a sufficient volume of incident reports around a specific theme like vaccination error at a local level, Pareto Charts can inform the design of local improvement projects. Feedback reports from the NRLS to organisations are one such application of this process. Quarterly safety reports (summaries of national data) from the NRLS and patient safety alerts (advice on specific clinical issues) distributed, for example, via the Clinical Alerting System in National Health Service (NHS) England, should be used by organisations to assess the status of those issues locally.2



  • Contributors PR wrote the original article with input and significant contributions from all previously mentioned authors. AC-S is the guarantor.

  • Funding This research is supported by the NIHR Health Services and Research Delivery programme (12/64/118).

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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