Recording and learning from patient safety events provides insight into what can go wrong in healthcare, and why. Effective recording supports learning. It improves patient safety, nationally and within practices.
When we inspect
We look at a practice’s processes and systems to monitor patient safety.
We will look at how practices respond to patient safety events. We look at how they:
- identify and assess risks and safety issues
- follow all relevant patient safety and medicines safety alerts
- record patient safety events and concerns
- report, respond, communicate, review and analyse these internally and externally (where appropriate)
- learn from patient safety events.
Recording patient safety events, both positive and negative, indicates a positive safety culture. Positive safety cultures encourage staff to be open and honest when things go wrong. Recording patient safety events can proactively improve safety.
We will expect practices to have a local process to record and learn from minor incidents and events. Read GP mythbuster 3 for information on reflecting and learning from incidents.
We will consider patient safety incident management when we review if the practice is safe and well-led. This relates to:
and key lines of enquiry (KLOEs):
- S1: Safeguarding and protection from abuse
- S6: Learning when things go wrong
- WL5: Management of risk and performance
The Learn from patient safety events (LFPSE) service
The LFPSE service is replacing the National Reporting and Learning System (NRLS). This new system, managed by NHS England and NHS Improvement, is a major upgrade. It creates a single national NHS system for recording patient safety events. It is a centralised system to record and analyse information. It is hoped that the new system will increase recording. This will allow for more effective learning from events, with patient safety improving.
Primary care staff are encouraged to use the system to record any events where:
- a patient was harmed or could have been harmed. For example, an unsafe discharge.
- there has been a poor outcome, but it is not yet clear whether an incident contributed or not.
- risks to patient safety in the future have been identified.
- safe and effective care has been delivered that could be learned from to improve patient safety.
A national learning system allows patterns and trends to be picked up more effectively as part of the national picture. This enables the NHS National Patient Safety Team to identify new or under recognised issues and take NHS-wide action. For example, issuing an urgent alert to protect patients.
The LFPSE allows for positive local responses to patient safety events. This supports effective management, mitigation and learning activities. Events recorded in LFPSE can be used for significant event analysis. They can also be used for continuing professional development and reflective practice. The LFPSE’s data principles explain how the data can be used.
The NRLS eForms for general practice are no longer in use. The eForms now redirect to the LFPSE login page.
Systems for recording patient safety events
All organisations registered with an Organisation Data Service code can use the LFPSE online service. This includes general practice, community dentistry and community optometry.
Providers can record patient safety events through the online recording service. This can include opportunities to:
- record information about events that could have, or did, affect the safety of patients
- record information about events that have gone well
- access, review and update event records through a searchable dashboard of relevant records
- undertake governance activities to support local patient safety response and improvement
- view data about what patient safety events have been recorded within their own organisation.
The LFPSE forms have been designed to be quick and simple to complete, while fulfilling national data requirements. Once logged in, staff can save drafts and return to update records, as needed. Staff do not need to have undertaken an investigation, or found a solution to the problem, before recording the patient safety event. The questions within the LFPSE have been user-tested. Guidance text helps select the right options.
We previously had access to GP incident reports reported to the NRLS. We will continue to have access to these through LFPSE. We use this data to understand how practices identify, respond to and learn from patient safety events to improve safety. LFPSE includes the option to state if a reported event requires a statutory notification to CQC. This will be auto populated for deaths and serious injuries.
Data collection will also include:
- notifications about death and if the patient was detained under the Mental Health Act
- notifications about death and if the patient was subject to Deprivation of Liberty Safeguards
- notifications of abuse/allegations of abuse and whether the event has been notified to the local authority
- if the event qualifies as:
- a notifiable safety incident under Duty of Candour regulations
- a Never Event/Serious Incident
- notifiable to the Healthcare Safety Investigation Branch.
Work is underway to decide how best to support patients and families take part in patient safety learning. Meanwhile, they can continue to record incidents using the existing patient eForm.