Learn from patient safety events (LFPSE) service

A new national NHS Learn from patient safety events service (previously called the patient safety incident management system – PSIMS – during development) is in the final stages of development as a central service for the recording and analysis of patient safety events that occur in healthcare. We have now commenced the public beta stage, where some organisations can begin using the system, instead of the NRLS.

LFPSE is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors.

LFPSE applications

LFPSE will initially provide two main services:

Record a patient safety event – organisations, staff and patients will be able to record the details of patient safety events, contributing to a national NHS wide data source to support learning and improvement. Once local systems are made compatible, larger organisations such as NHS trusts will record patient safety events to the national system via a direct upload from their Local Risk Management System (LRMS). Other organisations, such as primary care providers (see our dedicated primary care LFPSE webpage) can record patient safety events directly via the online recording service. A dedicated service for patients and families to use will be developed. In the meantime patients can continue to record incidents to the NRLS via the existing patient eform.

Access data about recorded patient safety events – Providers will be able to access data that has been submitted by their teams, in order to better understand their local recording practices and culture, and to support local safety improvement work.

How recording safety events supports patient safety

Recording safety events, whether they result in harm or not, provides vital insight into what can go wrong in healthcare and the reasons why.

At a national level, this allows for new or under-recognised safety issues to be quickly identified and acted upon on an NHS-wide scale, ensuring providers across the country take action to reduce the risk. It also provides a wealth of data offering essential insight to support ongoing national patient safety improvement programmes, as well as improvement work at a more local or speciality-specific level (find out more about how we use patient safety incident recording at a national level).

Public beta

LFPSE began its public beta stage in summer 2021. This is a final extended piloting stage where some organisations can begin using the system, instead of the NRLS.

During this stage:

  • Organisations that have upgraded their Local Risk Management System (LRMS) to a LFPSE compliant system can now start uploading safety events to LFPSE (see details below on ‘preparing for LFPSE’). All other organisations with an LRMS should continue to upload to the NRLS
  • Organisations without an LRMS, and their staff, can now register for an account and use the online Learn from patient safety events service to record safety events.

Further information for primary care organisations and staff about the introduction of LFPSE in those settings is available here.

How LFPSE will improve patient safety learning 

The new LFPSE service is a major upgrade, creating a single national NHS system for recording patient safety events. It introduces improved capabilities for the analysis of patient safety events occurring across healthcare, and enables better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning that are more relevant to the current NHS environment.

LFPSE will:

  • make it easier for staff across all healthcare settings to record safety events, with automated uploads from local systems to save time and effort, and introducing new tools for non-hospital care where reporting levels have historically been lower
  • collect information that is better suited to learning for improvement than what is currently gathered by existing systems
  • make data on safety events easier to access, to support local and specialty-specific improvement work
  • utilise new technology to support higher quality and more timely data, machine learning, and provide better feedback for staff and organisations.

Around three quarters of reporting to the NRLS and StEIS was from the hospital sector. LFPSE will make recording safety events easier in other care settings, including primary care, through the introduction of simple online forms, and a dedicated portal to access, review and update previously recorded incidents. This supports good incident response practice, by allowing smaller organisations to see all their safety events through one dashboard.

What LFPSE will do

The new LFPSE service is a major upgrade, creating a single national NHS system for recording patient safety events. It will introduce improved dimensions for the analysis of patient safety events occurring across healthcare, and enable better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning and are more relevant to the current NHS environment.

When fully functional, LFPSE will:

  • make it easier for staff across all healthcare settings to record safety events, with automated uploads from local systems to save time and effort, and introducing new tools for non-hospital care where reporting levels have historically been lower
  • collect information that is better suited to learning for improvement than what is currently gathered by existing systems
  • make data on safety events easier to access, to support local and specialty-specific improvement work
  • utilise new technology to support higher quality and more timely data, machine learning, and provide better feedback for staff and organisations.

At present, around three quarters of reporting to the NRLS and StEIS is from the hospital sector. The new safety learning service will make recording safety events in other care settings, including primary care, easier, through the introduction of simple online forms, and log-in access to review and update previously recorded incidents. This will also support good incident response practice, by allowing smaller organisations to see all their safety events through one dashboard.

Lucie Musset, product owner for LFPSE, describes what the new system will do and how it will benefit patient safety.

Developing the LFPSE service

LFPSE has been developed with staff from all health and care settings, following best-practice agile development methodology, and adheres to the Government Digital Service Standard. This means that design decisions are made around how best to meet specific user needs. It also means the service is developed one step at a time, so different functions will become available at different points, and the roll-out process will be a gradual one.

Upcoming additional functionality

To continue to meet identified user needs, throughout the public beta period new functionality will be added to the service as it is developed. This will include:

  • enhanced tools for accessing and visualising data, for the public, providers and national bodies
  • new feedback mechanisms and enhanced learning outputs
  • online forms so that patients and their representatives can report safety events directly (the NRLS Patient eForm will remain available for use until new online forms are fully developed).

Ongoing user research will take place throughout, to also identify any new needs for future developments.

Timescales for further roll out

Current timescales for introducing LFPSE are:

  • Public beta phase commenced summer 2021 – LFPSE is now available to NHS and independent sector providers with compatible LRMS, and other providers with ODS codes, using the online service
  • Public beta transition – providers move from NRLS to LFPSE as their LRMS compatibility upgrades become available – see ‘preparing for LFPSE’ section below (estimated completion mid 2022)
  • Live phase – once all providers have transitioned from NRLS to LFPSE, the service is officially live. (timing TBC – dependent on roll out of compatible local risk management systems – see below)

Throughout its life, we will work to continuously add to and improve the service so that it remains the best system for users and the NHS.

This page will be added to with further updates, supporting information and resources as we progress through the final stages of LFPSE development.

Preparing for LFPSE

Larger NHS organisations, such as trusts and foundation trusts, usually have a dedicated local risk management system (LRMS) for reporting incidents. Incident data is then uploaded onto the national NHS system (the NRLS or LFPSE).

LRMS suppliers are rolling out a programme of upgrades to move organisations onto products that are compatible and compliant with the LFPSE service, supporting two-way communication between local and national systems, and allowing automated data sharing. Providers should contact their LRMS supplier for further details.

We have a web page providing a list of LRMS vendors who have achieved PSIMS compliance who are able to offer LFPSE-compatible products.

Smaller organisations, such as general practice, independent dental surgeries, community pharmacies and opticians, may not have their own LRMS. In these organisations, staff can now record patient safety events directly to LFPSE online. Further information can be found on our LFPSE primary care webpage.

Staff who report incidents using NRLS staff eForms will be redirected to the LFPSE recording service and asked to register for an account. They will still be given the option to record anonymously.

To support local safety governance, response and improvement, LFPSE also offers organisations without an LRMS the ability to assign individuals access to data on all safety events recorded within their organisation, and to complete statutory and national policy reporting and response requirements as necessary.

This web page provides information on the different types of LFPSE accounts, and who should use them.

Accessing data recorded to the LFPSE service

Providers sharing details of patient safety events with LFPSE can access their own data, in line with how they currently access NRLS data. There are tools for simple online visualisations of the data, and a download function allowing providers to blend LFPSE data within their own business intelligence software. We will also continue to publish national aggregated data for both NRLS and LFPSE while they exist in parallel.

Over time, we will develop self-service tools to support routine and ad hoc analysis of national LFPSE data, in line with our agenda of transparency, and to facilitate more opportunities to derive improvement insight from the information we hold, and to share learning outputs across the NHS.

Additional information

More information about the project, it’s roll-out, getting help including signing up and for organisations with or without local risk management systems, is available in our frequently asked questions.

For further information about LFPSE and the Beta service you can also view a PSIMS show and tell video recorded in July 2020.