Head of Patient Safety (Primary Care) NHS England, Dr Martyn Diaper, on the importance of reporting and learning from incidents
Human error – it’s not about blame; it’s about learning.
That’s the important message to take away about reporting incidents in primary care. One of the Health Secretary’s favourite sayings is about how he wants the NHS to become the world’s largest learning organisation, and that starts with reporting incidents.
Despite the high number of patient contacts, the number of patient safety incidents reported by GPs and practice staff is decidedly low.
In general practice we have around 360 million patient contacts in England every year: estimates of how many people we harm are around one in 100. If you do the maths that works out at 3.6 million patients who experience an avoidable harm every year.
That doesn’t sit very comfortably but it is very real, and we have an obligation to reduce the amount of harm caused to these patients.
Despite the high number of patient contacts, the number of patient safety incidents reported by GPs and practice staff is decidedly low.
In fact, we have seen a slight decline in recent years to fewer than 4,000 reports each year, compared with the 1.5 million and rising coming from secondary care providers.
This creates a real loss in opportunities to learn valuable patient safety lessons from the 360 million general practice consultations each year.
Given the sheer number of patients seen in general practice, it is inevitable that on occasions things will go wrong. Whether this is because of human factors, faulty equipment, administrative errors, or system problems – these all have the potential to cause harm to patients and are largely preventable.
So why aren’t people in primary care reporting?
One of the arguments is that the harms that occur in general practice aren’t severe harms. If you look at the Never Events list very few of them apply to general practice.
But harms do still happen.
Figures from the Primary Care Trigger tool by the NHS Institute show that around 10% of prescriptions given out a day have an error on them, and one in 20 patients end up in hospital as a result of the medicines prescribed for them by their doctor. An even more alarming figure affects over 75s – about one in four are harmed by the care they receive.
A study conducted by Imperial College, where researchers spoke with GPs and patient safety personnel in north-west London, highlighted two key elements of why there is a lack of reporting in primary care. The first is there is a lack of understanding about what constitutes a patient safety incident and, secondly, GPs fear blame.
The lack of understanding and fear is no different to that experienced by secondary care clinicians over a decade ago when reporting systems were first introduced – we now receive upwards of 1.5 million reports each year of patient safety incidents for national learning from this setting.
General practice as a whole needs to move past this mindset of fear and realise that reporting is a good thing. Increased reporting from a practice or organisation indicates an open and just culture exists, where staff feel empowered to report and learn for the benefit of their patients.
As one step to overcome these barriers, we have developed a new GP eForm, in collaboration with general practice, to make it quick and easy for practice staff to report incidents for national learning.
The GP eForm takes minutes to submit a report. An automatic bounce back email with a SEA template and feedback on reporting is sent when a report is submitted. This will support team-based learning and can be used as part of CPD, appraisal and revalidation.
"Increased reporting from a practice or organisation indicates an open and just culture exists, where staff feel empowered to report and learn for the benefit of their patients".
Anyone working within a practice could be involved with or witness a patient safety incident; therefore reports can be submitted by any member of the team, from GPs to administrative staff.
Practices can choose whether or not they want to include their practice code when submitting a report. Including this data enables us to share information with local NHS England teams and, if the practice opts to, with their CCG to support local learning and actionable solutions. However, the reporter can choose to report entirely anonymously.
Early data since the launch of the GP eForm in February 2015 indicates an encouraging rise in reporting from general practice, with the majority of practices reporting incidents that have taken place within their practice and using their practice code to identify themselves.
We will continue to work together with GPs, practice staff, commissioners and patients to introduce a truly just culture of open reporting and learning to enhance patient safety in primary care.
Find out more
Watch our short video on Dr Diaper’s talk here
Access the GP eForm here
Get more information here
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