Patient Safety Zone

Primary Care patient safety resources

This page provides links to several QI resources especially relevant in primary care. These include educational information on a number of QI methods, safety checklists relevant to primary care and report forms to help you complete QI reports. The frameworks used in the peer review of QI projects are also included.

Quality improvement in primary care: what to do and how to do

Ensuring patients receive care that is safe and of high quality is an essential part of modern healthcare. To help with this, there are growing numbers of evidence-based Quality Improvement (QI) methods that can help practitioners to assess and improve the care they provide. However, for many, the experience of QI has often been felt to be “audit for audits sake” or a huge amount of work in an ever-increasing workload.To make things easier, this resource describes several QI methods that will be useful for all members of the primary care team who wish to better understand and apply QI thinking and tools more effectively. 

Download the Quality Improvement in Primary Care Booklet

  • Quality improvement in primary care : what to do and how to do it ( Download, 2 MB)
Criterion-based Audit

Criterion based audit involves selecting aspects of health care and systematically evaluating them against explicit criteria and agreed standards. Where indicated, changes are implemented at an individual, team or practice level to meet those standards. Further monitoring is used to confirm improvement in healthcare delivery.

Download the Criterion-based audit tool

Significant (Learning) Event Analysis

SEA involves a structured team meeting, where participants reflect on and analyse identified significant events to understand what happened, the impact and contributing factors. This leads to reflection and learning to direct improvements to systems.

Click here to find out more

GP Specialty Trainee Safety Checklist

The NES Safety and Improvement team have worked with trainers in the West of Scotland to update the GP trainee safety checklist. This contains safety critical areas that should be understood by trainees early in their GP placement and it hoped it is useful as part of induction and to direct future learning.

Download the Safety Checklist for Educational Supervisors in GP Training

  • Safety Checklist for Educational Supervisors in GP Training ( Download, 25 KB)
Incident Reporting
Incident Reporting

Incident reporting helps teams and organisations to identify the type, frequency and severity of adverse incidents.

Why is incident reporting important?

Before attempting to resolve any problem you first need to become aware of it! Incident reporting helps teams and organisations to:

  • Identify the type, frequency and severity of adverse incidents (what went wrong where with who?)
  • Consider the causes of the incidents (Why did it go wrong?)
  • Learn from the incidents
  • Share this learning with colleagues
  • Implement changes to minimize future recurrences

Incident reporting is more likely to occur in an environment and culture where people feel psychologically safe. Listen to Professor Amy Edmonson of Harvard Business School on developing psychological safety in workplaces:

  • Click here for video link.

What to report?

You should report all patient safety incidents. There are a number of national reporting systems in addition to local NHS Board reporting systems that collect specific data systematically.  Their findings and recommendations are published periodically.

National reporting systems:

Download this PDF for information about Incident Reporting.

How to Report an Incident

Your NHS Board will have one or more paper or computer-based reporting systems with dedicated support staff. This information is normally included in induction programmes. 

For incidents involving staff, patients and the public you will need to complete an Incident Record 1 (IR1) form to report what happened. The IR1 will prompt you to also report the incident to the Health and Safety Executive (HSE) if necessary.

In primary care settings the term ‘significant event’ has historically been used to include all patient safety incidents as well as examples of good practice.

A significant event is any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice, team or organisation.

 

Analysing the Incident

There are a number of tools that may help you analyse and learn from an incident, including:

  • Root cause analysis (RCA)
  • Significant event analysis (SEA)
  • The Incident Decision Tree (IDT)

Root Cause Analysis (RCA) is a method that is used to try and find the cause(s) of a serious incident.

It usually involves a trained multidisciplinary group and may include people that were not involved in the incident.  It is time and resource intensive and may not be feasible for individual health care workers.  

A Significant Event Analysis (SEA) seeks to answer four core questions:

  • What happened?
  • Why did it happen?
  • What has been learned?
  • What has been changed?

Teams and individuals are encouraged to share their findings, reflections and learning during dedicated meetings.  SEA is embedded in primary care as part of contractual, educational and appraisal obligations

Access Significant Event Analysis resources here.

Incident decision tree (IDT)

The Incident Decision Tree helps managers and senior clinicians decide initial action to take with staff involved in a patient safety incident. Access the National Patient Safety Agency's incident decision tree.

Culture and Communication

Culture