The Primary care patient safety strategy was published in September 2024.
The strategy builds on the wider NHS Patient Safety Strategy (2019) and describes the specific national and local commitments to improve patient safety in primary care, including learning from patient safety incidents.
The strategy highlights patient safety training for staff, and modernised incident recording and response systems.
It focuses on:
- developing a supportive, learning environment and just culture in primary care, with sharing across the system so that the services can continually improve
- ensuring that the safety and wellbeing of patients and staff is central, and that our approach to managing safety is systematic and based on safety science and systems thinking
- involving patients in the identification and co-design of primary care patient safety ambitions, opportunities and improvements
Given the capacity pressures in primary care and ICBs, the strategy seeks to continuously improve patient safety through existing processes and structures as much as possible, rather than adding work. The timeframes for the implementation are intentionally flexible to allow for the piloting of different approaches, and while this strategy is for all areas of primary care, some improvements will be implemented first in general practice and the successes and learning then used in the rollout to community pharmacy, optometry and dental services.
In summary:
- safety culture: participate in the NHS staff survey
- safety systems: complete patient safety syllabus training
- insight: register for and use the new incident recording (LFPSE) and incident response (PSIRF) systems
- involvement: identify patient safety leads and lay patient safety partners
- improvement: review and test patient safety improvements in diagnosis, medication, referrals, optometry and dental services
Community pharmacy and dental services have both developed specific groups to support patient safety improvements sharing ideas and innovations: the Community Pharmacy Patient Safety Group and Project Sphere.
For further information and support for General Practices or PCNs who want to start implementing key elements of the strategy please contact the ICB quality and patient safety team primary care lead Jenny.singleton@nhs.net
Primary care patient safety strategy overview
Learning from Patient Safety Events for primary care
Primary care information on the new national learn from patient safety events service
All healthcare staff in England, including those working in primary care, are encouraged to use the Learn From Patient Safety Events System (LFPSE) to record any events where:
- a patient was harmed, or could have been harmed
- 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
- good care has been delivered that could be learned from to improve patient safety.
NHS England and NHS Improvement manage the national learn from patient safety events (LFPSE) service, a centralised system to record information and offer data and analysis about patient safety events to support safety improvement across all care settings.
LFPSE is now in use by all Trusts in NEL ICS and many primary care organisations have already set up an account.
LFPSE system provides two main services:
- Record a patient safety event – organisations, staff and patients can record the details of patient safety events, contributing to a national NHS wide data source to support learning and improvement.
- Access data about recorded patient safety events – providers and commissioners can access data that has been submitted by their teams, in order to better understand their local recording practices and culture, and to support local safety improvement work.
Recording primary care patient safety events on LFPSE
Use the link below to find out how to set up or access an account.
NHS England » Primary care information on the new national learn from patient safety events service
With a LFPSE account, users can log in to review and update records they have previously drafted or shared, and can use an easy summary-print option to keep copies to support CPD and personal reflection.
Graded account permissions mean that different staff can access different levels of data to support good governance and data quality. This includes using a filterable dashboard of all events recorded within their organisation.
Those holding an administration account are in control of their organisation’s LFPSE permissions, so you can be assured that the right people within your teams are able to fulfil oversight and governance responsibilities appropriately, and that the service can be used to fit your locally-established processes.
Find out more about the different LFPSE accounts.
See the new Introduction to LFPSE.
The Care Quality Commission
The CQC encourages Primary Care staff to use the new LFPSE system to record patient safety events including medicines-related incidents.
Events recorded in LFPSE can be used for significant event analysis and for continuing professional development and reflective practice. GP mythbuster 24: Recording patient safety events with the Learn from patient safety events (LFPSE) service – Care Quality Commission
A Guide to responding proportionately to patient safety incidents
Involving patients in patient safety
Engaging and involving patients, families and staff following a patient safety incident
The term engagement describes everything an organisation does to communicate with and involve people affected by a patient safety incident in a learning response. This may include the Duty of Candour notification or discussion, and actively engaging patients, families, and healthcare staff to seek their input to the response and develop a shared understanding of what happened.
Compassionate engagement describes an approach that prioritises and respects the needs of people who have been affected by a patient safety incident.
Involvement is part of wider engagement activity but specifically describes the process that enables patients, families, and healthcare staff to contribute to a learning response.
Use the Patient Safety Incident Framework Engaging and involving patients, families and staff following a patient safety incident guidance
Further information is also available
NHS England » Framework for involving patients in patient safety
Introduction to PSIRF (Patient Safety Incident Response Framework)
The Patient Safety Incident Response Framework (PSIRF) is a new approach to learning from patient safety events in a way that leads to improvement in care.
Many practices already have processes for learning from safety events and taking action to prevent future harms. PSIRF helps ensure these processes produce meaningful improvement.
PSIRF is underpinned by four principles:
- Compassion: engaging meaningfully with those affected by patient safety events (including staff and patients), through answering questions, and addressing concerns, and involving those affected in any learning response.
- Systems-thinking: understanding how a safety event happened and not who to blame. This includes exploring work conditions and processes.
- Proportionality: focusing effort where there’s the greatest potential for learning and improvement. This avoids bureaucracy that drains time and deflects resources away from improvement activity.
- Supportive leadership: Leaders engage and empower, asking questions to understand rather than to judge. Leaders enable improvement and collaboration by creating a psychologically safe workplace that encourages honest conversation.
PSIRF offers a set of tools and techniques that help practices become more proactive. Instead of responding to one event at a time, PSIRF allows for lessons to continuously build upon past improvement, making processes safer, more efficient, and more effective.
PSIRF provides a modern toolbox of learning response methods and guidance on developing safety actions that practices can choose from to best suit their needs or the needs of an individual safety event. This includes huddles, multidisciplinary team reviews and after-action reviews.
PSIRF’s focus on improvement can:
- Shift culture away from blame and bureaucracy.
- Enable generation of meaningful insight.
- Improve staff well-being.
- Improve the patient experience.
- Provide timely and accurate learning about systems and processes.
Working collectively under PSIRF can:
- Reduce duplication of effort through agreeing shared improvement goals.
- Increase engagement in improvement activity.
- Improve the culture of recording and sharing.
- Enable shared learning and improvement across practice boundaries.
- Provide access to skills and resource to support systems thinking and compassionate engagement.
NHSE advises Practices to work collectively to adopt PSIRF and develop a patient safety incident response plan. Practices could work together across a Primary Care Network (PCN), GP Federation, wider neighbourhood group or ICB geography.
If any Practices or PCNs are interested in developing PSIRF please contact the ICB quality and patient safety team lead for primary care
Jenny.singleton@nhs.net
System Engineering for Patient Safety SEIPS-quick-reference-and-work-system-explorer
Patient Safety Culture
Patient Safety Culture
Safety culture is one of the key foundations of the primary care patient safety strategy.
A positive safety culture as one where the environment is collaboratively created and nurtured so that everybody (individual staff, teams, patients, service users, families, and carers) can flourish to ensure brilliant, safe care.
There are three key elements
- Continuous learning and improvement of safety risks
- Supportive, psychologically safe teamwork
- Enabling and empowering speaking up by all
However, staff can sometimes feel unsafe and unsupported by the culture and systems that surround them. In terms of systems this has been described as the structures and processes within a practice, the organisational arrangements that surround a practice, the wider interactions with other providers of health and social care, and the influence of regulatory bodies.
There are two myths that can undermine a safety culture, both of which are held at times within the NHS including primary care:
- perfection myth: if we try hard enough, we will not make any errors
- punishment myth: if we punish people when they make errors, they will not make them again
The NHS Just Culture Guide can be used to support a consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents.
It is supported by a number of organisations including the BMA, GMC, RCN, Royal Pharmaceutical Society and Nursing and Midwifery Council.
Training
Patient Safety Training
Patient safety training materials have been published by NHS England and NHS Improvement, The Academy of Medical Royal Colleges and elearning for healthcare.
Completion of the training will help to ensure health and care services are as safe as possible for patients and service users.
The training has five levels, which build on each other, the first two levels Essentials for patient safety and Access to practice are available on the elearning for healthcare hub.
The first level, Essentials for patient safety, is the starting point and all NHS staff are encouraged to complete it. This training is free and level one takes about 30 minutes to one hour. It is recommended for all staff and is mandatory training in the ICB and most NEL Trusts.
Level one also provides an additional session for senior leaders: Essentials of patient safety for boards and senior leadership teams.
Level two, Access to practice is intended for those who have an interest in understanding more about patient safety and those who want to go on to access the higher levels of training.
There are two sessions in level 2: The first introduces systems thinking (how the way we work can be used to reduce error and improve safety) and risk expertise (how we can identify and manage risk to keep patients safe). The second session looks at human factors (the science of work and of working together in safely designed systems) and safety culture (the significance of a true learning culture, free of inappropriate blame). Level two – Access to Practice includes an assessment and a certificate on completion of the assessment.
Patient Safety Videos/Podcast
Patient Safety Incident Response Framework (PSIRF) in General Practice – Middlewood Partnership
This is a video interview with Dr Paul Bowen, General Practitioner, Medical Director, and Partner at the Middlewood Partnership and Primary Care Network (PCN) about his approach to introducing the principles from the PSIRF to improve safety and culture across the PCN.
The video is also available on the NHS Futures website where you will find more information in the workplace – NHS patient safety
FutureNHS Collaboration Platform – FutureNHS Collaboration Platform
Podcast
Applying PSIRF in general practice by NHS England
In this podcast, Tracey Herlihey from NHS England’s national patient safety team talks with Jenny Coverley from Middlewood Practice in Cheshire about her experience applying PSIRF principles in general practice and for her PCN.
Introducing the Learn from Patient Safety Events service
This video describes the Learn From Patient Events Service, a new way to record patient safety events, and how it can be used to improve patient care.