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Join Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in collaboration with Radar Healthcare for an engaging discussion on Learning from Patient Safety Events (LFPSE) and the Patient Safety Incident Response Framework (PSIRF), highlighting their combined impact on patient safety improvement. This webinar will delve into pivotal aspects crucial for integrating LFPSE and PSIRF into your incident and reporting software, including: User-Centric Approach: Understand the significance of aligning LFPSE and PSIRF principles with the end-user's perspective, ensuring a seamless and intuitive experience. Success Story: Learn how GSTT implemented both LFPSE and PSIRF, surpassing standard levels of incident reporting and advancing patient safety practices. Data Empowerment: Discover how GSTT was able to address its patient safety priorities and facilitate the provision of critical data to the national patient safety improvement programs led by NHSE. This session will spotlight how GSTT adapted to new processes and frameworks like LFPSE and PSIRF, contributing to both national and local safety initiatives. Speakers: Charles Martin, Trust Head of Risk and Quality Assurance - Guy’s and St Thomas’ NHS FT Paul Johnson, CEO - Radar Healthcare Jack Forshaw, Project & LFPSE Lead - Radar Healthcare Chair: Jon Hoeksma, CEO - Digital Health Register

To mark this year’s World Patient Safety Day (WPSD), the Royal College of Surgeons of Edinburgh (RCSEd) will be running a series of blogs and Talking Heads on key surgical and dental topics in this area. These have been provided by patients, families and carers, alongside members of the College’s Patient Safety Group, College Council and the wider College fellowship. The College’s eleven Surgical Specialty Boards (SSBs) have been asked to provide blogs on how patient involvement in their individual specialty has helped to drive up standards of care. The blogs will provide examples of how patients and carers can play vital roles in making decisions about their own individual care and also how they can enhance the safety of the healthcare system as a whole by contributing to strategic decisions at organisational level. Two blogs will be released on each day of the College’s week-long WPSD campaign, starting on Monday 11 September and leading up to WPSD on Sunday 17 September. Members and Fellows will have access to these through the College website following the campaign. RCSEd blogs Who World Patient Safety Day 2023 Engaging patients for patient safety Giving-back Harper Lee's law campaign Truth and compassion The privilege of working with medical students: a World Patient Safety Day blog by Eddie Mcgill Shared decision making an essential step in optimal patient care Enhancing patient safety in cardiothoracic surgery The role of patient involvement groups in the UK Engaging patients for patient safety patients are given new voices by NHS England Team based quality reviews Exploring the crucial role patients play in enhancing surgical research Remote PSA monitoring for prostate cancer patients using digital platforms. A safe and efficient follow-up alternative to traditional face-to-face outpatients Patient participation for safe service re-design Co-creation with stakeholders in information production is key to high quality patient-centred care Engaging patients for patient safety. Dentists can elevate the voice of patients RCSEd commitment to patient safety Upholding patient safety and ensuring the highest possible standards of patient care have been at the heart of the College’s activity since it was founded over 500 years ago. The Patient Safety Group supports and coordinates all the College’s Patient Safety initiatives. We have a multidisciplinary membership drawn from all the faculties of the College and including representation from both the wider surgical team and patients themselves. Over the years, the College has worked hard to develop numerous resources to help improve patient safety. These have taken many forms and include: Patient, Carer Support: The Patient Safety Group has worked hard over the last few years to develop high quality, innovative and accessible resources to support surgical and dental patients and their carers. It is hoped that these resources will help patients to better navigate surgical care and empower them to be advocates for their own health. Training Courses: These include the highly successful NOTSS Programme, PINTS Course and DeNTS Course, which aim to educate the whole peri-operative team in the non-technical skills which underpin safe operative surgery and dentistry, and the innovative ICONS workshop which was developed with patients to provide training in sharing the complex decisions involved in informed consent. Web-based Resources: These include the Surgical Ward Round Toolkit which aims to reduce errors and improve safety on surgical ward rounds. Patient Safety Webinars: This very popular 10-part series featured contributions from renowned world experts in the patient safety arena drawn from a wide range of disciplines. Let’s Talk Surgery Patient Safety Podcasts: These experts have also contributed to the College’s podcast series allowing more in-depth personal discussion on key Patient Safety topics. All sessions were recorded and remain available to College members and fellows on the Education section of our website. Surgeons News Articles: The Patient Safety Group has published a large number of articles in Surgeons News covering a broad range of patient safety topics. MSc in Patient Safety and Clinical Human Factors: We have also worked with the University of Edinburgh as part of the Edinburgh Surgery On-Line Programme to develop an MSc in Patient Safety and Clinical Human Factors. This 3-year part-time programme supports any graduate health care professional in using evidence-based tools to improve the safety of everyday health care systems. National Campaigns: These include the very successful LetsRemoveIt campaign, running since 2017, to reduce bullying and undermining, and its resultant detrimental effect on patient safety, in the surgical and dental workplace. A large range of resources have been developed to help in this area and the College were instrumental in forming the anti-bullying alliance with other national bodies. National Guidelines: The College have also developed several national guidelines to influence healthcare policy & improve the working environment, such as Improving the Working Environment for Safe Surgical Care and Improving Safety Out of Hours. Staff Resilience and Wellbeing: We also recognize that staff resilience and wellbeing is a major factor in helping to ensure safe patient care. Improving surgical team wellbeing and mental health has been a major focus for the College over the last year. The College Trainees’ Committee has taken the lead in this and the Patient Safety Group have been proud to support them in this endeavour. The Committee have run very successful wellbeing weeks over the last three years. These raised the awareness of the importance of wellbeing amongst all members of the surgical team and included various activities such as daily webinars, virtual workshops and sessions on cooking, mindfulness, yoga, art and how to make work fun. CPD points for the webinars in the series were provided, underlining the importance that the College places on this subject. The College’s 'Moon and Back’ campaign, launched in 2021, encourages all members of the surgical team to take time out of their busy schedules to focus on their mental health. We are also proud to be able to endorse the Royal Australasian College of Surgeons Wellbeing Charter for Doctors which describes the principles that guide the wellbeing of doctors and the shared responsibilities for wellbeing of the medical profession. Please visit the College’s website and social media channels for more information on all these patient safety resources. It is great to be able to share these with you and to help raise awareness of the importance of patient safety in our everyday surgical and dental practice.

The Learn from Patient Safety Events (LFPSE) service is the NHS's new system for the recording and analysis of patient safety events. Very little research had been done before to understand the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Learning from patients’ experiences and how they feel about the care they have received is known to be a very good way to make healthcare services better. However, getting the right information from people in the right way, and making sure the right NHS staff see it and can act on it, is difficult to do. This Show and Tell outlines the research completed to understand how we can do this better through the introduction of the LFPSE service. Audience: This is a publicly open event for anyone interested in understanding the work that NHS England has completed into understanding the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Speakers: Lucie Mussett Patient Safety Lead & Senior Product Manager for the Learn from patient safety events (LFPSE) service Hope Bristow – Senior User Centred Designer (Informed Solutions) Natasha Hughes – User Researcher (Informed Solutions) Register

The publication of the New Patient Safety Incident Response Framework in August 2022 has shifted the focus towards identifying and investigating patient safety incidents and events that have the greatest potential to lead to learning and improvement. This conference focuses on patient safety learning – maximising learning and improvement from patient safety insight and events. The conference will support you to identify incidents and insight that has the greatest potential for improvement and use a range of system-based approaches for learning from patient safety incidents. The conference will also update delegates on the new Learn from patient safety events (LFPSE) service and how local incident reporting will adapt to this new system. The roles and competencies of the Learning Response Lead, and the practicalities of involving and engaging with patients to deliver continuous improvement will also be discussed. Finally the conference will share examples of Safety Actions & After Action Reviews which is recommended under the new framework. This conference will enable you to: Network with colleagues who are working to improve the learning from Patient Safety Insight and Events. Update your knowledge on the New Patient Safety Incident Response Framework published in August 2022. Ensure your approach to learning is in line with PSIRF. Understand the new roles of Patient Safety Partner, Patient Safety Specialist and Learning Response Lead. Identifying and prioritise incidents that have the greatest potential for learning. Explore the requirements and value of the Learn from patient safety events (LFPSE) service. Reflect on the perspectives of a patient who has been engaged as a patient safety partner, and understand how to engaging and involving patients, families and staff can lead to improvement. Understand behaviours, decisions and actions that allow continuous learning and improvement. Develop practical approaches to better aligning the work of patient safety and quality improvement teams. Understand how to work with staff to ensure a focus on learning and continuous improvement. Develop your skills in Leading Patient Safety Improvement and techniques for ensuring a system-based approach to learning. Identify key strategies for delivering Safety Actions & After Action Reviews: Delivering, accountability and monitoring. Supports CPD professional development and acts as revalidation evidence. This course provides 5 hours training for CPD subject to peer group approval for revalidation purposes. Register We have five free places for hub members. To secure the places, simply quote HCUK00PSL.

On the 13 February 2025, the Health Services Safety Investigations Body (HSSIB) published a report exploring how patient safety is managed across different organisational boundaries. This forms part of a series of reports looking at Safety Management System principles and their application to health and care. In this blog, Patient Safety Learning sets out its reflections on the findings of this investigation. HSSIB investigates patient safety concerns across the NHS in England, and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report looks at patient safety issues across organisational boundaries, by exploring the safety management activities of Integrated Care Boards (ICBs).[1] An ICB is a statutory NHS organisation responsible for bringing NHS and other partners together to plan and deliver services in an Integrated Care System (ICS). ICSs are partnerships that bring together organisations in specific geographical areas—there are currently 42 across England.[2] This HSSIB investigation focuses on the experiences of Ros and her husband and carer Norman, using their case to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS. Reflecting on the findings of this report, in this blog we focus on four key subject areas: safety management systems reporting and learning from patient safety incidents ICBs and ICSs patients still having to join the dots of patient safety. Safety management systems The HSSIB report forms part of a series looking at the application of a safety management systems (SMSs) approach to health and care. HSSIB define this as: “A safety management system (SMS) is a proactive approach to managing safety that is used in other industries. It sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.” There is a growing debate about the potential benefits of moving towards a SMS approach in healthcare, which is widely used to manage safety in different industries. HSSIB states that such an approach has four key components: Safety policy—establishes senior management's commitment to improve safety and outlines responsibilities; defining the way the organisation needs to be structured to meet safety goals. Safety risk management—which includes the identification of hazards (things that could cause harm) and risks (the likelihood of a hazard causing harm) and the assessment and mitigation of risks. Safety assurance—which involves the monitoring and measuring of safety performance (e.g., how effectively an organisation is managing risks), the continuous improvement of the SMS and evaluating the continued effectiveness of implemented risk controls. Safety promotion—which includes training, communication and other actions to support a positive safety culture within all levels of the workforce.[3] However, as the findings of their report highlight, we are currently a long way removed from such an approach in our health and care system. Emphasising this, it states: “There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety.” The report notes a particular gap around the role of ICBs, referencing the NHS Oversight Framework, which describes how oversight of NHS trusts, foundation trusts and ICBs operates. It highlights that this does not specify the day-to-day patient safety management activities to be undertaken by ICBs. The report’s key recommendation in this area is as follows: “HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.” Patient Safety Learning supports this recommendation. We think that a country-wide SMS would have the potential to provide a more structured and joined up approach to patient safety strategies, involving all the national bodies. We believe that integral to this is a standards-based framework to ensure safety, quality patient care, consistently delivered.[4] A patient safety standards framework helps organisations understand ‘what good looks like’ for patient safety and where more action is needed for improvement with clearly defined safety aims and goals. Such a framework will enable organisations and regulators to demonstrate a risk-based approach to patient safety and evidence achievement. It can provide assurance that patient safety sits at the organisation’s core, improves performance through increased effectiveness, and enables patients and families, staff, funders and communities to identify and differentiate good safety providers. This is a point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape being led by Dr Penny Dash.[5] Reporting and learning from patient safety incidents In the last couple of years, the NHS has been transitioning to a new system for recording and analysing patient safety incidents. The former National Reporting and Learning System (NRLS) has been gradually phased out, with organisations moving onto the new Learn from Patient Safety Events (LfPSE) service.[6] This HSSIB investigation highlights a number of concerning issues relating to how effectively the LfPSE service supports the identification and management of patient safety risks across organisational boundaries. The report notes difficulties accessing and using data from the system with less analysis tools available compared to the previous NRLS. Worryingly, it states: “ICBs suggested that they needed to be building a picture of ICS risks, including those which involved cross-organisational boundaries, but they could not currently do this because of the usability of the LFPSE service and data.” The report does note that in response to these concerns some ICBs have developed local adaptations to compensate for this lack of visibility of patient safety risks within providers. It also says that NHS England has indicated it is developing a new Recorded Data Dashboard for LfPSE that will allow for greater analysis of incident records than was possible with NRLS. Considering these concerns, HSSIB makes the following safety observation: “Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.” On these issues, we feel more robust action is required. Sharing learning from patient safety incidents is a fundamental component of improving patient safety and delivering safe care. That LfPSE is not currently providing the means to analyse and share cross-organisational learning represents a significant missed opportunity. As the findings of the report demonstrate, local fixes, which may not be applied consistently across the NHS, are now required because of ICBs lack of visibility of patient safety risks within providers. At Patient Safety Learning we also have related concerns about the availability of LfPSE data beyond ICBs. Currently, individual trusts can see reports of their own data but not system-wide information to help them assess risk or engage with others. This can create a siloed approach where individual trusts or departments may benefit from their data but fail to contribute to a wider culture of safety improvement. We are also troubled that the outputs of local learning responses and safety incident investigations under the new Patient Safety Incident Response Framework (PSIRF) are not widely shared either within or across ICBs. We understand that the new initiatives, PSIRF and LfPSE, are intended to align so that there is a comprehensive and system-wide analysis with reports on the causes and contributory factors of avoidable harm and action needed to make improvement. However, this alignment is not currently reflected in practice. This is not an acceptable situation. The existing gaps in the LfPSE service are not simply a technical issue with a new digital service. They will result in missed opportunities to identify patient safety risks, learn from them and ultimately prevent avoidable harm to patients. We believe the Department of Health and Social Care and NHS England must now prioritise the development and improvement of LfPSE and its integration with PSIRF. Integrated Care Boards and Integrated Care Systems A theme that runs throughout the HSSIB report is the lack of clarity around the roles of ICBs and ICSs in patient safety. Its key findings highlight this, noting: “There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability.” This lack of clarity can also be seen in a number of other examples in the report: Inconsistency in how ICBs have reported processes and responses when escalating safety risks to NHS England. If these do not fall within existing programmes of work, responses were described as “hit and miss”. Uncertainty about whether ICBs have oversight of provider collaboratives in relation to patient safety. This was described by an NHS England respondent as a “big black hole”. Varying approaches to safety management activities by ICBs. The report notes that while some undertake assurance visits, “these are limited by capacity and ICBs described a reliance on more reactive activities such as responding to incidents which had already occurred”. In a further example of this lack of clarity, at one point the report notes: “… a senior manager at NHS England told the investigation that while there is an expectation that ICBs will manage cross-organisational safety risks, NHS England “have not told ICBs they have to” do this or “flagged this” in planning or operational guidance. The investigation acknowledges that PSIRF guidance refers to management of cross-organisational safety risks. However, this does not direct how cross-organisational safety risks should be managed more generally outside of PSIRF.” Patient Safety Learning believes action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our report, The elephant in the room: Patient safety and Integrated Care Systems.[7] One means of addressing this gap could be through implementing a SMS approach in health and care, with ICBs and ICSs tasked with a clear leadership role for system safety. This is another point we recently highlighted in our submission to the independent review of patient safety across the health and care landscape.[5] We believe that there is potential at an ICS level to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patients still having to join the dots of patient safety At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. We identify this as one of our six foundations of safer care in our report, A Blueprint for Action.[8] The importance of patient feedback is reflected in the HSSIB report, which notes that: “Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard.” There is no doubt that insights and feedback from patients and carers can provide ICBs with valuable information on patient safety risks, within organisations and across organisational boundaries. However, this must be accompanied by a structured and resourced framework for gathering these insights otherwise the visibility of these insights are likely to favour those patients and carers who are more adept and confident at making their voices heard. As noted by Norman in his own reflections on his carer role for Ros: "Norman told the investigation that he was getting the care Ros needed through his actions and that he was aware of other patients whose families did not have as strong an advocate as him. He said this affected their ability to get the care they needed, and that 'there are a lot of us out here trying to look after patients'.” While points around safety management systems, LfPSE and ICB/ICS roles and responsibilities can appear detached from day-to-day care, ultimately their impact comes back to the patient. As noted by the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, patients impacted by avoidable harm and unsafe care often have to ‘join the dots of patient safety’ in response to systemic failures.[9] If we fail to address these systemic failures, they will result in patient safety risks that come with a very real human cost. References HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025. NHS England. What are integrated care systems? Last accessed 10 February 2025. HSSIB. Safety management systems: an introduction for healthcare, 18 October 2023. Patient Safety Learning, Standards: What Good Looks Like, Last accessed 10 February 2025. Department of Health and Social Care, Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. NHS England. Learn from patient safety events (LFPSE) service, Last accessed 10 February 2025. Patent Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. The IMMDS Review, First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020.

Healthcare providers are always seeking ways to enhance patient care and safety. Successful implementation and execution of new frameworks, like Learning from Patient Safety Events (LFPSE) is a crucial tool for achieving this. In this blog, risk quality and compliance software provider, Radar Healthcare, covers everything you need to know about LFPSE V6: what it is, its importance, best practices and more. What is LFPSE Taxonomy V6? The LFPSE is a standardised framework designed to categorise and report patient safety incidents in healthcare settings. Its purpose is to facilitate better data collection, reporting and analysis, which ultimately aims to improve patient outcomes and care quality. Building on the current live version (LFPSE V5), LFPSE V6 serves as a significant improvement, enabling more efficient collection and submission of patient safety incidents to enhance patient outcomes. What are some of the challenges to consider? LFPSE Taxonomy V6 is designed to be compatible with most healthcare systems, but some integration challenges may still arise. Ensuring your current system supports the new taxonomy and safely transferring existing data to the new system are critical steps. Overcoming adoption challenges such as resistance to change can be managed through training and demonstrating the benefits, while technical issues require close collaboration with IT for a smooth implementation. Additionally, there are costs to consider, including purchasing or upgrading software to support the new taxonomy and investing in staff training and development programmes. Top tips for implementing LFPSE Taxonomy V6 Define your organisational goals first: Begin by aligning your internal objectives with the requirements of NHS England. Although there are established frameworks, it’s crucial to tailor incident report plans to address the specific risk factors of your local area. While LFPSE mandates the collection of certain key incident data, you must also identify and focus on key risk areas pertinent to your local context to meet national reporting standards effectively. Assess your current systems and processes: Evaluate your existing incident reporting systems for compatibility with LFPSE V6. Consider whether your current systems can communicate with each other to prevent duplication. Ensure that your governance and incident reporting processes can meet the new standards effectively and efficiently. Remember that it is okay to re-evaluate and make necessary adjustments to maintain its effectiveness and compliance. Train and support your workforce: It is important to provide comprehensive training for all relevant staff members on the new taxonomy and how to correctly fill in and submit the forms to ensure smooth adoption and efficient use. Future-proof your strategy and system: Ensure that the processes and systems you implement for LFPSE V6 are flexible, scalable, and capable of adapting to future enhancements and changes. Consult with your current software provider and team to confirm this flexibility. Utilise user feedback: Gather feedback from multiple stakeholders across your organisation. Adopting a user-centric approach ensures that the needs and experiences of end users are prioritised, leading to a more effective and user-friendly implementation. Closing remarks Successfully navigating the transition to LFPSE V6 is essential for healthcare providers committed to enhancing patient safety and care quality. By understanding the challenges, setting clear goals, evaluating current systems, training staff, and incorporating user feedback, organisations can effectively implement this improved framework. For more insights into LFPSE V6 and Radar Healthcare becoming the first to be accredited by NHS England, check out this Q&A with their LFPSE Champion, Jack Forshaw. Further reading on the hub: NHS England: Introducing the Learn from Patient Safety Events (LFPSE) service Homerton's guide to implementing Learn from Patient Safety Events (LFPSE) into Datix Southern Health: LFPSE presentation for staff NHS England podcast: Machine learning and LFPSE – revolutionising how we learn from patient safety events Policy guidance on recording patient safety events and levels of harm RLDatix and NHS England LFPSE webinar