Learn from Patient Safety Events (LFPSE) Service – frequently asked questions (FAQs) updated November 2022
Any healthcare provider with an ODS code can record patient safety events to the LFPSE service, irrespective of which service type they are delivering.
Providers who currently report to the NRLS must transition to the LFPSE service by April 2023. We also expect to see increasing uptake from across Primary Care, and other sectors which have been traditionally low reporters to the NRLS.
The LFPSE service aims to improve learning through a number of means:
· Supporting recording from a wider range of health settings, specifically via the online service for those without a Local Risk Management System (LRMS) who have traditionally been very low-participation groups.
· Updating the taxonomy to capture more mechanistic details of how things go wrong, rather than inflexible lists (which conflate incidents, outcomes, contributory factors, etc and so fail the basic purpose of a data collection taxonomy), to allow us to develop targeted interventions to improve safety where they will be most effective.
· Providing new kinds of analysis, looking at common factors across safety events, to be supported by machine learning, and prioritisation based on more nuanced combinations of information than just levels of harm.
· More rapid collation of data via Application Programming Interfaces (APIs) instead of clunky manual extract-and-upload processes, allowing us to respond faster to national safety issues.
· Making data more accessible and transparent, and providing a platform for users to meaningfully collaborate and share learning and improvement resources, to help good ideas spread.
These services will grow over time, and with input from users.
There is a wealth of information for providers on the FutureNHS platform, and software vendors wishing to become LFPSE-compliant can find more details on our Compliant Vendors page.
Recording individual patient safety events is a voluntary process, except where reporting to NHSE fulfils duties for other statutory mandatory requirements, such as reporting notifiable incidents to CQC (we share data routinely with CQC to avoid the need for providers to have to duplicate – see our Terms and Conditions).
However, the NHS Standard Contract states that “The Provider must ensure that it is able to report Patient Safety Incidents to the National Reporting and Learning System and to any system which replaces it’’ (SC33.2), to support both national safety interventions, and as the basis for a positive safety culture and enabler of safety improvement locally.
All providers must transition from NRLS by 30 March 2023, or by 30 September 2023 where the availability of compliant local risk management software precludes connection by March 2023.
No. LFPSE has been designed for use in all healthcare settings, as a key part of the national Patient Safety Strategy. We have further information about using it in Primary Care available here, and CQC has published a Mythbuster, on how they will be using the data, here. Mythbuster,on how they will be using the data, here.
Yes, both form part of the wider NHS Patient Safety Strategy. The LFPSE and Patient Safety Incident Response Framework (PSIRF) teams work closely on a daily basis, and have been collaborating to design a new PSIRF module in the LFPSE service, which will be rolled-out at the same time as the new policy.
A LFPSE module to support the roll-out of the new Patient Safety Incident Response Framework (PSIRF) is currently in its Alpha phase, being developed with input from the PSIRF Early Adopters. It will be made available in time for the wider roll-out of PSIRF in 2023. Until then, providers should continue to follow the Serious Incident Framework and record their Serious Incidents on the StEIS. STEIS will be decommissioned once all providers have transitioned to PSIRF via the LFPSE.
Yes, provided each record meets the core mandatory LFPSE dataset to enable submission, you can configure your local risk management system to capture any other fields you require locally. Only fields from the LFPSE taxonomy will be uploaded to the LFPSE service, as these fields have been specified to support national learning. Speak to your LRMS supplier about the best ways to configure recording your local additional fields when upgrading to a LFPSE-compliant software version.
No. The only change to quality assurance of records is that the API sends an update every time a record is amended, from the first submission. All local information assurance processes should continue to be followed, but this change means the national team can be more responsive to emerging issues, and duplicate submissions will no longer cause problems locally or nationally. National surveillance processes have been amended to accommodate this change, with the understanding that initial data may not be of the desired quality and records may change frequently in the early days after initial capture.
Providers who are submitting data to the LFPSE service will be able to access their organisation’s own data through online tools, and ICBs/ICSs can access the data of their relevant providers when they set up an account and request appropriate permissions. Full records can be viewed via the Dashboards in the Online recording service. Aggregate 15-month data can be viewed in the Data Access app.
National data will also be published. Later this year we will be adding tools to allow more self-service national data to relevant users, such as professional organisations and specialty-specific learning groups, to support learning activities. In the meantime, those wishing to access LFPSE data for patient safety learning and improvement should contact the team on email@example.com.
All providers who currently report to the NRLS need to transition to the LFPSE service by April 2023.
Both LFPSE data and NRLS uploads via a LRMS will be available during the transition, with the view to decommissioning NRLS and archiving its data once all providers have transitioned to LFPSE. Organisations without a LRMS, and their staff, should now register for an account and use the online Learn from patient safety events service to record safety events. Staff previously using the NRLS eForms are now redirected to the new online LFPSE service.
We recognise how important it is for patients and families to be able to share their concerns about unsafe care. The LFPSE service aims to include this facility, and to do so in a way that makes sense to people navigating the complexities of healthcare delivery. We want to create a recording tool that sits appropriately amongst other well-established feedback channels, such as complaints processes, without requiring patients and carers to do a lot of work to establish what is feedback for national learning, and what is better aimed at their provider(s), so that they get the responses they deserve. This will take time, as the complaints process is enshrined in law, so cannot be altered quickly.
We have work planned for 2023 to explore this further, and in the meantime, patients and families can continue to use the NRLS eForm, which is looked at by the national Patient Safety team regularly, which is looked at by the national Patient Safety team regularly.
We want this service to work as well as possible for users, and so in line with agile principles, we want your feedback to ensure that all LFPSE service capabilities are helping improve the way healthcare is delivered. If you have ideas for enhancements to the service or wish to be involved in the development of any of the forthcoming modules, please contact firstname.lastname@example.org.
We encourage all users to avoid submitting PII wherever possible. However, if PII is accidentally submitted, one of the first ways we are using Machine Learning (ML) in the LFPSE service is in the anonymisation software we have developed to redact any identifiable details from the main free text fields. This uses a ML algorithm, backed up by rules-based learning, and finally our team of Data Quality Officers, whose feedback will continue to train and improve the accuracy of the model on live data.
The models have been tested on old NRLS free text and reached acceptable reliability metrics for live use.
Development costs including apps used by national Patient Safety staff for their statutory functions around review and analysis, the PSIRF module and NRLS decommissioning total £4.2M from 2017 to 2022.
For context, the NHS Patient Safety Strategy estimates that almost 1,000 extra lives and £100 million in care costs could be saved each year from 2023/24 by its full implementation, including the delivery of LFPSE. The potential exists to reduce claims provision by around £750 million per year by 2025. We have been assured by LRMS vendors that there will be no direct cost in upgrading to LFPSE-compliant versions of their software. However, some support contracts may require local spend on implementation. Further details can be found on our Compliant Vendors page.
The Development of the Patient Safety Incident Management System (DPSIMS) was the working title for the project to develop LFPSE. The “Learn from patient safety events” (LFPSE) service is the output of the DPSIMS work. You can read more about this name change here.
The National Patient Safety Team (NHS England) have a statutory responsibility to collect and learn from safety information, including patient safety incidents – defined as ‘unintended or unexpected events (including omissions) in healthcare that could have or did harm one or more patients’ – and to provide associated advice and guidance to the National Health Service (NHS). To support this responsibility we can and do use safety information relating to ‘healthcare’ where that healthcare is delivered by NHS providers, as well as by non-NHS providers when commissioned to deliver healthcare services to NHS patients.
We do not have a remit for collecting or acting on information regarding provision of social care services that are not related to NHS funded healthcare, but would encourage recording of information about NHS funded healthcare to the LFPSE service from social care providers, should they be aware of information that would support the aim of making NHS funded healthcare safer for patients.