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Key findings The study findings suggest that the designation of a NE as a NE is dependent on the individual/type of NE and that NEs were reportedly rare. Although GPs were more likely to disagree with the NE label for the more frequently occurring NEs, this was not in proportion to their increased frequency of occurrence. Most GPs remained unconvinced that the risk can be eliminated for any of the NEs. GPs do, however, seem to take the actual and potential occurrence of such events seriously given that 99% stated an intention to undertake a significant event analysis after a NE. Opinions varied widely with some GPs commenting that the risk of serious harm was extremely low, whereas other GPs suggested that the NE should be more stringent. Some GPs felt that the NE description was placing a burden of responsibility on them that was not intended by the description of the NE; for example, that they should be responsible for the actions of a laboratory or the ambulance service. There were differences in opinion about the level of responsibility a GP should take for the actions of non-medical staff.

This paper presents a narrative review of the evidence relating to the quality and safety of locum medical practice. Its purpose is to develop our understanding of how temporary working in the medical profession might impact on quality and safety and to help formulate recommendations for practice, policy and research priorities. The authors conclude that there is very limited empirical evidence to support the many commonly held assumptions about the quality and safety of locum practice, or to provide a secure evidence base for the development of guidelines on locum working arrangements. It is clear that future research could contribute to a better understanding of the quality and safety of locum doctors working and could help to find ways to improve the use of locum doctors and the quality and safety of patient care that they provide.

The toolkit is designed to be used by the whole primary care team within the GP practice or out of hours setting. These resources can be used flexibly, either as standalone materials or as part of an integrated package. The Royal College of General Practitioners do recommend that all resources are used if this is feasible. Using the TARGET Antibiotics Toolkit resources will enable primary care organisations to demonstrate compliance with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance.

I am a GP in Northampton and for some time, around 2006, I was concerned that my practice did not have a robust system for monitoring patients on dangerous drugs such as methotrexate and azathioprine. We tried to keep a manual database for our patient register, but with patients stopping and starting these drugs, moving in and out of the practice, and needing different tests at different time intervals, it was a really difficult task, and I suspected that we were missing patients and, therefore, it was hard to keep track of who needed reminding regarding tests. I tried working with my Practice Manager to create a more sophisticated spreadsheet in Microsoft Excel, then when that failed, within Microsoft Access. Again, we kept on coming across problems and I knew we hadn’t cracked the problem yet. Then I started talking to Tim – Tim is an IT software developer and, while we were watching our children’s swimming lesson, I was explaining to him the complexities of what I was trying to achieve, and he immediately took up the challenge and promised to write me a bespoke programme. Two years later and many Sunday afternoons spent drinking oodles of cups of tea, Neptune was created. We have been successfully running Neptune in my GP surgery since 2008, following which we introduced it to four beta testing sites. The system worked remarkably well from the start and very quickly we expanded to other local practices. Over the past 2 years we have been fortunate enough to roll out across the whole of Leeds Clinical Commissioning Groups (CCGs)(approximately 100 GP practices). Neptune’s success lies in its simplicity. It is a relational database that stores information about as many drugs as you would like, such as generic and brand name, BNF category and what monitoring tests are required. It uses three simple reports from the GP practice system to upload patient, drug and testing information and then puts this all together into a reminder list and either prints reminder letters, sends an email through a secure nhs.net account or produces an SMS text alert via MJOG. If the patient does not respond to their reminder, then a second reminder and then a third reminder is sent, with the final reminder being an alert to the prescribing GP. Like all new developments, we have faced a few challenges along the way. Not least was how to roll out to 100 practices in Leeds which is a long way from Northampton. We brought other members on to our team, and now have two trainers and two other software support as well as me and Tim. We love going into GP practices and seeing how everyone has tackled this problem differently, or not at all in some places. We have found, in general, the better the system already in place, the more Neptune is appreciated as the practice already appreciates what a difficult task this is. Neptune continually evolves and we love to change according to user feedback. We are now on to version 4, with version 5 just around the corner. Our current project is to include not just CCG defined amber drugs for the Near Patient Testing Direct Enhanced Service, but all drugs that require monitoring such as diuretics, ACE inhibitors and thyroid drugs. This will increase the patient population that Neptune monitors considerably, but the impact on patient safety will be immeasurable and, hopefully, will improve safety, reduce hospital admissions and, ultimately, iatrogenic harm and even death. We would love to roll out Neptune to as many practices as possible as we believe this is the best, most accurate and efficient way of performing this challenging task.

Results: Participants who had experienced some level of harm were able to comment more extensively on safety aspects of care. Several key themes related to safety were identified from the analysis of all participant narratives. An assumed sense of safety in general practice was predominant, and was influenced by participants' level of risk awareness and trust in their general practitioner. Additional unique themes included feelings of vulnerability, desire for an explanation and apology, a forgiving view of mistakes, and preference for GP interpersonal skills over competence. Conclusions: This study revealed new insights into the factors that influence patients' and carers' perspectives of safety, and demonstrated the value of incorporating the patient voice into safety research. An assumed sense of safety due to a default position of trust, coupled with limited risk perception, directly contests the current literature on patient involvement in safety. Further exploration is required to determine how patients and carers can effectively engage in and assist with improving safety in general practice.