The Patient Safety Collaborative

Making a difference - Prevention Systems for Patient Safety

About us

MISSION
To share insights so that participants learn from each other’s experiences. Through developing partnerships and fostering the cross fertilisation of ideas, experience and expertise between healthcare professionals, clinical governance and risk managers, healthcare managers and medico-legal and ethics experts, the Collaborative will assemble the most relevant, practical knowledge and expertise to deliver solutions and best practice in Patient Safety in Primary Care.

BACKGROUND
Patient Safety is high on the government’s agenda and the recently established National Patient Safety Agency (www.npsa.org.uk) has been tasked with a key role in bringing patient safety to a national level, enabling the entire NHS to learn from incidents and make itself safer and more stress free for patients.
The NPSA faces many challenges in achieving its aims that are relevant to the entire healthcare sector - fear of reporting; what to report; how to report and how to interpret and analyse the data and provide feedback in a positive manner so that meaningful changes are made.
However, there are additional and unique problems when it comes to the Primary Care sector:

1. To date, limited research had been undertaken to understand the rate, character, or consequences of errors occurring in primary care. General practice is characterised by “customised” care that responds to individual patients’ needs, values and preferences. Compared to hospital based care, this allows for greater practice variation, more common and expected deviation from evidence-based guidelines and possibly therefore greater scope for unanticipated negative outcomes of care.
2. Existing incident reporting and/or risk management systems in secondary care can be readily adapted to this new tasks to be imposed by the NPSA, whereas primary care organisations on the whole will have to develop their own systems from scratch.

3. The organisation of Primary Care into relatively autonomous and larger units (Primary Care Groups and Primary Care Trusts) is still in its infancy and such organisations have not yet had the time to fully develop and impose uniform IT policies, systems and quality control systems amongst their membership.

4. The establishment of new systems in secondary care organisations is relatively easy as they tend to be large and concentrated in a small number of locations. However, this is not the case in Primary Care, which is organised into large numbers of small units.

Unless these problems are addressed and a meaningful, unified political voice is heard, Primary Care faces the real danger of systems, rules and procedures designed on the basis of knowledge and experience gained in the hospital setting for reporting and dealing with patient safety issues being imposed on primary care, which may prove to be impractical, unrealistic and overly burdensome.