Purpose 

This guidance sets out NHS England’s approach to developing and maintaining effective systems and processes for recording prescribing-related patient safety incidents for the purpose of learning and improving patient safety. For clarity, patient safety incidents are unintended or unexpected events (including omissions) in healthcare that could have harmed or did harm one or more patients.

Should I record a prescribing incident?

Incident recording is very much encouraged. If in doubt, it is always better to record a patient safety incident using the available information and best judgement. The General Pharmaceutical Council (GPhC) standards for pharmacy professionals require pharmacy professionals to help people ‘maintain and improve their health, safety and wellbeing’. GPhC standards for the initial education and training of pharmacists state: “patient safety must come first.” Therefore, patient safety and wellbeing are an essential consideration when delivering pharmacy services. Ultimately determining when an incident has occurred, the extent to which that incident has caused harm, and the level of harm caused, are all judgements. The GPhC has published a Pharmacy team toolkit to support learning from incidents.

To support these judgements, NHS England’s policy guidance on recording patient safety events and levels of harm sets out the definitions of ‘patient safety incident’ and ‘good care’ event types, level of harm, and answers some frequently asked questions relating to the recording of incidents.

In line with 8 (2) (c) (iii) of Schedule 4 of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (and subsequent amendments) and the NHS England approved particulars, pharmacy contractors are required to maintain a patient safety incident log for all incidents and should record any incidents that meet the national definition of a patient safety incident to the Learn from patient safety events (LFPSE) service. Further information on who should use the LFPSE service, how to implement it, and other frequently asked questions (FAQs) is available online via the LFPSE service webpage.

Recording the appropriate level of harm associated with a patient safety incident is important so that:

• we have an accurate description of the incident and its impact on the patient, based on the best information at the time
• there is consistency and comparability within the organisation’s own data
• the National Patient Safety Team can use the recorded information to analyse, triage and learn from consistent and high-quality data
• other policies such as duty of candour can be enacted appropriately

How do I record an incident?

To record patient safety incidents via the LFPSE service, pharmacy contractors without a LFPSE-compliant local risk management system (LRMS) will need to input information directly via an online account. Some pharmacy contractors may have an existing LFPSE-compliant LRMS and should continue to record patient safety incidents via that route, which will in turn connect to the LFPSE service. For more information about how the LFPSE service is being rolled out to organisations with a LRMS, please see the main project webpage.

Pharmacy contractors should include the prompt code ‘COIN1’ when recording incidents relating to NHS commissioned prescribing-based services via the LFPSE service. This will allow the National Patient Safety Team to identify these incidents for analysis. It is recommended that incidents are initially recorded as soon as possible, and no later than five working days after the incident occurred/is discovered. Additional information can be added to the LFPSE service records as the incident is managed / reviewed. Pharmacy contractors are expected to work towards a complete and accurate record of a patient safety incident over time.

The LFPSE service has been extensively tested to make it accessible and user-friendly and is in continuous development. There is also a national helpdesk to support with any technical queries around using the online service.

In addition to recording incidents via the LFPSE service, pharmacy contractors should ensure that incidents are reported to their ICB where a local reporting process in is place.

How does the LFPSE service support safety improvement?

When things go wrong in care, or even when they go right, it is vital patient safety incidents are recorded to ensure learning can take place to support local and national patient safety improvement.

By recording patient safety incidents via the LFPSE service, you are participating in an NHS-wide effort to share patient safety data that is vital to our national safety improvement work, while also supporting local responses to patient safety incidents.

Having a national incident management system for the NHS allows patterns and trends that are not visible locally to be picked up more effectively as part of the national picture, enabling our National Patient Safety Team to identify new or under recognised issues and insights, and to take NHS-wide action, such as issuing an urgent alert to protect patients. The team also work with partners on a range of other responses to identified risks, and share data to support ongoing programmes tackling more common safety issues.

More information can be found on the NHS England Using patient safety events data to keep patients safe webpage.

Using the LFPSE service to support safety improvement in primary care

The LFPSE service has been developed to be more suitable for use across all healthcare settings.

This change is important as less than 1% of the 2.2 million records received by the LFPSE service’s predecessor, the National Recording and Learning System (NRLS), each year were from primary care, despite this being where most patient interactions take place. At a national level, this provided only limited information about patient safety incidents occurring in primary care, limiting our effectiveness to support improvement and resources in these settings.

Through the LFPSE service, the data collected is structured in a way that directly supports our understanding of the state of safety within all areas of healthcare delivery. The National Patient Safety Team analyse this data for maximum learning benefit, and to generate insights that can change the way we work to improve the safety of care for all our patients.

Approved particulars

NHS England publishes approved particulars relating to the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, as amended. Whilst these approved particulars refer to dispensing incidents, they are applicable to all patient safety incidents. This includes prescribing incidents.

Resources

Further LFPSE service resources are available via the NHS Patient Safety workspace on the Futures collaboration platform (a log in is required).

Publication reference: PRN02380vii