Reviewing patient safety events and developing advice and guidance

The patient safety review and response and advice and guidance teams perform a core function within the National Patient Safety team,  working to review and analyse sources of information on patient safety events to identify new or under recognised risks.

These teams then lead on the development of advice and guidance to support the NHS to address those risks, such as National Patient Safety Alerts.

The process is supported by a wide range of registered healthcare professionals representing a variety of clinical specialties, many of whom work on wider patient safety policy and projects.

Additionally, we access clinical and topic expertise both internally and externally when required.

How we review records of patient safety events

The role of the team starts with the clinicians in our National Patient Safety Team reviewing information from the National Reporting and Learning System (NRLS), the Strategic Executive Information System (StEIS), and also the new Learn from Patient Safety Events service (LFPSE), as well as a range of other sources, to identify new or under-recognised issues that may need national action.

The team currently review around 32,000 records of patient safety events each year. Sources of this information include:

  • Patient safety events recorded on our national systems as resulting in death or severe harm, or that meet other thresholds for clinical review
  • Selected categories of Serious Incidents reported to StEIS
  • Potential and confirmed Never Events reported to StEIS
  • Patient safety events recorded on the NRLS by patients and the public (we review all of these whether they result in harm or not)
  • Letters from coroners where they have identified a need for action to prevent further deaths (Regulation 28 letters)

Focused reviews

Where our review suggests there could be a new or under-recognised issue that requires national action, we explore further. Our decision to undertake a focused review can often triggered by a single patient safety incident, which we then explore to understand if there is a wider patient safety issue.

We do this by looking to identify any patterns in similar incidents previously reported, including no harm ‘near miss’ incidents – with a focus on what could go wrong in future. This focused review process sees the team analysing several thousand further records of lower harm patient safety events each year.

Deciding what action to take

Where new and under-recognised risks are identified, not all issues will require a National Patient Safety Alert.

As part of that decision process we:

  1. Check whose remit an issue falls under, as some aspects of patient safety are handled by other national organisations and we can pass to them for action.
  2. Look for up-to-date detail about the issue in the NRLS, research studies and other published material, and seek advice from specialists and frontline staff to help identify the likelihood of this happening again, and the potential for harm, including the risk of death or disability.
  3. Consider if the patient safety issue can be addressed at source – for example, by the manufacturer of a device – and if it can, whether this will happen rapidly enough for no other action to be required.
  4. Talk to experts, patients and frontline staff to identify if the patient safety issue is new or under-recognised; these groups may have different perspectives.
  5. If it is new or under-recognised, explore whether organisations can do something more constructive than simply raising awareness and warning people to be vigilant against error, and the options for these actions (including interim actions while more robust barriers to error are developed).
  6. If the patient safety issue is well known, including if it was the subject of an earlier Alert, we recognise that substantial efforts will already have been made to address it, and further improvements will need more support than can be provided by a National Patient Safety Alert alone. We will consider if there are new or under-recognised resources or interventions.
  7. Consider if a National Patient Safety Alert is the best route; if actions only require changes in practice by a professional specialty, rather than wider action by healthcare teams or organisations, they may be more effectively communicated by a professional society, such as a royal college.

You can also view our National Patient Safety Alert decision flowchart.

Who advises us?

Insight to help us understand each patient safety issue and to develop the required actions for our Alerts mainly comes from frontline staff, patient representatives, professional bodies and partner organisations on our ‘National Patient Safety Response Advisory Panel’.

This panel is made up of:

  • 20% patient and public voice
  • 40% frontline staff from providers and commissioners from all healthcare sectors
  • 40% key national and professional stakeholders

As a member of the National Patient Safety Alerting Committee (NaPSAC), we have developed and improved our processes for issuing National Patient Safety Alerts and were the first organisation to be accredited to issue this new national standardised format for alerts.

The standards set for National Patient Safety Alerts ensure that the safety-critical and mandatory actions an Alert requires organisations to take, are clear, feasible and effective.

Examples of how we have responded to the risks we’ve identified

Supporting the NHS’s response to specific healthcare issues

At particular times our patient safety review and response work is tailored to include surveillance of specific healthcare issues arising at a point in time, such as the impact on patient safety of supply chain challenges or emerging diseases, such as Covid-19.

Initiating specific surveillance at such times provides early signals of new and emerging risks to patient safety and supports our aim to provide rapid advice and guidance to the NHS.

Supporting ongoing improvement work

The information we collect through our national systems also supports ongoing improvement work to tackle the more common and well-known patient safety challenges, such as reducing diagnostic error, preventing self-harm, avoiding falls or managing long-term anticoagulation.

These issues have complex causes and no simple solutions, and are the focus of long-term improvement work, including the NHS England and NHS Improvement National Patient Safety Improvement Programmes.

We also have extensive arrangements for sharing records of patient safety events with other national bodies, royal colleges, professional societies, and researchers, so they can review and act on issues that relate to their specific areas of patient safety responsibilities or expertise.

Partnership learning from specialist review of patient safety event data

We regularly share data with a number of clinical and professional networks that review records of patient safety events and use their findings to support safety improvements in their specialty.

These include:

  • the Royal College of Emergency Medicine, which shares its findings in safety flashes
  • the Safer Anaesthesia Liaison Group, which shares its findings in quarterly patient safety updates and uses them to inform wider guideline development
  • UK Health Security Agency (formally Public Health England), which shares its findings in Safer Radiotherapy reports
  • the MHRA, which uses NRLS data to inform its regulatory functions for medication and medical device safety
  • the UK Kidney Patient Safety Committee, which shares its findings in patient safety updates
  • the Health Safety Investigations Branch (HSIB), which uses NRLS and Serious Incident data to provide wider context to their specific investigations.

We also share data on patient safety events with organisations and researchers who are looking into a specific patient safety topic. Data on patient safety events also regularly appears in journal publications.

The impact of our review and response work

Our national review and response work is a key part of the NHS patient safety strategy, which estimate 160 lives and £13.5 million in treatment costs are saved every year from the resulting advice, guidance and other outputs.  Other parts of the strategy are also interlinked and support this work such as the roll out of the new national patient safety event recording system, LFPSE, which will introduce machine learning to support and improve how we analyse records of patient safety events. Work to further develop a patient safety culture across the NHS also helps our efforts by staff being more open and honest when things go wrong to support safety improvement without fear of blame.