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National Patient Safety Agency

Reporting and learning from patient safety incidents in general practice

12 June 2008


Yesterday (Wednesday 11 June) the National Patient Safety Agency (NPSA) and Nottinghamshire County Teaching Primary Care Trust co-hosted an event in Eastwood, near Nottingham, to share learning from a joint project undertaken  to engage general practice in reporting and learning from patient safety incidents.


Currently the NPSA receives approx 3-4,000 reports about patient safety incidents every day.  However, an overwhelming majority of these incidents occurred in acute trusts or general hospitals.  In comparison less than 0.4% of reports come from general practice.  This is only about 2,500 reports per year. 


The seminar, which was attended by 90 staff from Primary Care Trusts, general practice, Deaneries and Royal College of General Practitioners Faculties from across  England, highlighted ways to encourage reporting of incidents from general practice. 


Speaking at the seminar, Joanna Parker, NPSA said: “Our aim is to encourage more general practices to report patient safety incidents on a regular basis.  95% of the contact patients have with the NHS take place in a general practice setting so it is vital that we learn from incidents that take place here.  As a result of feedback from today’s seminar we will look at ways to work in partnership with general practice, primary care trusts and the Royal College of General Practitioners to improve the level of incident reporting and ensure that any learning is appropriately focussed.”


An NPSA feasibility study with a small number of general practices found that a range of measures needed to be implemented in order to increase incident reporting.  These include making reporting easier and simpler to do, clarifying definitions of a patient safety incident and increasing knowledge and understanding about the work of the NPSA.


The seminar also heard how Notts County PCT carried out a review of significant events that had happened in its constituent General Practices to better identify ways to facilitate and support practices to report incidents, both to the PCT and to the National Reporting and Learning System. The review also identified common themes to enable learning and reflection when incidents occur. This piece of work is now being adopted by other organisations.




Notes for editors:


For further information contact Amelia Lyons on 020 7927 9580 or amelia.lyons@npsa.nhs.uk


The National Patient Safety Agency encompasses the National Research Ethics Service, Patient Safety Division and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes. For more information about the Agency and its activities please visit our website www.npsa.nhs.uk.


About Nottinghamshire County Teaching PCT:


In October 2006 Nottinghamshire County Teaching Primary Care Trust (tPCT) took over the functions and responsibility from six former PCTs - Ashfield, Broxtowe and Hucknall, Gedling, Mansfield District, Newark and Sherwood and Rushcliffe PCTs.


The PCT plans and pays for the healthcare of 650,000 people in Nottinghamshire. In 2007/08 more than £770m will be spent on buying care for the people of Nottinghamshire.


The PCT is responsible for all community NHS services, such as district and school nursing, health visiting, GPs, dentistry, opticians, and pharmacy and it employs more than 3,000 staff.


One of its key responsibilities is to improve and protect the health of the local population by tackling health inequalities, such as reducing smoking, which is the major cause of cancer.


It is also in charge of allocating money to local NHS trusts, such as Nottinghamshire Healthcare Trust, Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation Trust, to buy services for patients living in Nottinghamshire County.

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