Following the inquiry into the deaths at Mid Staffordshire NHS Foundation Trust, The Berwick review (2013) cites a promise to learn and a commitment to act, and called upon the NHS to become a system devoted to continuous learning and improvement. In 2019 was the introduction of the NHS patient safety strategy derived from contributors of 527 organisations and individuals (staff, patients, carers and family members). Its aim is to be a collective intent to improve safety, to significantly improve the way in which we learn, and treat both staff and patients who are effected by events.
The organisational learning which occurred during the Covid pandemic, was captured by the chartered institute of ergonomics and human factors, in the document Achieving sustainable change, which highlighted learning goals, learning for everyone, the depth and speed of learning, learning from every day work, and learning both formally and informally. This context of looking at sustainability in change, allows for reflections around humanistic capturing the work as done versus the work as imagined (protocols/process/guidance documents). Helping to understand where the trade-offs occur and adoptions to such process, which supports the approach of patient safety incident response framework (PSIRF).
What is PSIRF?
The PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.
Is this applicable to primary care and general practice?
Research tells us that the study of patient safety in primary care settings has not caught up to that of secondary care, despite common perceptions that primary care is relatively low risk care. However, in May 2024 30.8 million appointments were delivered across GP practices and primary care networks, of which 44.3% of all appointments were same day, which is indicative of acute concerns.
Therefore, with the sheer volume of patient contacts which creates an increased risk of patient safety incidents (PSI) which is typically referred to as events or circumstances that may have or did result in patient harm. General practice usually refers to events such as these as significant events, and will typically initiate a significant event analysis to establish “what went wrong”…
That last statement is incredibly powerful, because the aim of PSIRF is to focus on what went right, what happened in all the occasions where care was delivered, what process was in place, what was the work environment doing to support such good practice, what individuals were involved. It encourages an approach of learning from good, just as much as learning from harm, which means it helps to create ‘just cultures and psychologically safe spaces for clinical colleagues to conduct compassionate conversations, and to learn without fear of judgement and supports a strengthened response to functions, and improvements.
What are a systems based approach to learning from safety events?
The focus of a system-based approach is examining the components of a system (e.g. person(s), tasks, tools and technology, the environment, the wider organisation) and understanding their interdependencies (i.e. how they influence each other) and how those interdependencies may contribute to patient safety.
This is derived from the system engineering initiative for patient safety (SEIPS) model:
A system-based approach recognises that patient safety is an emergent property of the healthcare system: that is, safety arises from interactions and not from a single component, such as actions of people. A system-based approach therefore recognises that it is insufficient to look only at one component, such as only the people involved. A system-based approach will identify where changes need to be made and then monitored within the system to improve patient safety.
Patients perspective
Research into the patient’s voice and the patient’s stories and experiences when it comes to clinical safety is very insightful, and helps to give a level of context to ensuring that all parties are involved and included in the new PSIRF approach to primary care.
Examples that relate to medication issues:
- “He prescribed and kept her on a high dose of steroids for a longer period than she should have been on without monitoring it, and just kept repeating her prescription every time she went in.”
- “Her GP took her off a medication that had been prescribed to her by a heart specialist which was facilitating her pacemaker to work effectively at regulating her heart.”
- “When the pharmacy looked at the prescription, they noticed that the GP hadn’t linked the impact of my Parkinson’s medication on the steroids, and they said that it would have a serious impact on my health if I took the drugs.”
- “The medication is actually contraindicated for people who have asthma so she probably should never have given it to me in the first place because I have asthma.”
- “I was alerted then to the fact that the ingredient I was allergic to might be in the prescription that he gave me. I read the leaflet and found that yes, there was Metoclopramide in it”
The PSIRF approach, provides recourses around responding to patients and family members when there is a safety incident, and this goes beyond what one covers in their “duty of candour” training.
The importance that can lead to improvement
Safety is clearly a significant interest and important to primary care practitioners and their patients, there is often a great deal of work that goes into management of the current significant event analysis (SEA), and the desire to continually strive for quality improvements. While many practices manage SAE and document their reviews, and meetings, and actions, very few, view the events with a wider lens, are there patterns in the existing risks, and there emerging risks, that will not present when reviewing events in isolation? Are there missed opportunities for wider learning because there is minimal qualitative and quantitative analysis? How well is this data triangulated, how often are themes shared to broaden input and understanding? This modelled by the example below, where cross current learning may be limited event within GP practices.
NHS England have been collaborating with various stakeholders across general practice, in the development of the general practice PSIRF introduction. The Health Innovation Network is also piloting this across the sector, at practice, PCN, federation and integrated care board (ICB) level to support wider learning from case studies.
Joanna Fox
Mrs Joanna Fox l CMgr FCMI, FREC, FPMA, ACIEHF, PGCert, CEBA, ACIPD, ACCA Cert, IOSH, HND Sc, Prince2, MSP & QSIR Practitioner. MSc Y2 Patient Safety and Clinical Human Factors.
For more information on how PCC can support contact enquiries@pcc-cic.org.uk or visit https://pcc-cic.org.uk/practice-support/.
