In July 2021, NHS England rolled out the national Learn From Patient Safety Events (LFPSE) service — a centralised system that healthcare staff can use to record and access information related to patient safety events nationwide using the NHS database.
As an LFPSE-compliant vendor, we’re writing a series of blog posts to help healthcare professionals better understand this new incident recording system. You can check out our previous articles here:
#1 The Five W’s of LFPSE — The New Incident Reporting System in the UK.
#2 Lucie Mussett - LFPSE Project Lead at NHS England Breaks Down the New Incident Recording System
#3 5 Reasons Why You Need MEG's LFPSE-Compliant Incident Reporting System
This is the last blog in our series and focuses on answering one simple but fundamental question —
All Said and Done, What Is ‘Learning’ in Patient Safety Anyway?
Patient safety is a critical aspect of the healthcare system that has received significant attention in recent years. It is fundamental to providing high-quality, effective and efficient care, improving patient outcomes, and preventing adverse events. It is also an essential factor for building trust between patients and healthcare providers.
That's why it is crucial for healthcare organisations and professionals to understand the various concepts and practices that contribute to overall patient safety. And therein comes the concept of 'learning'.
Understanding the Concept of ‘Learning’ in Patient Safety
Learning, in the context of patient safety, refers to gaining knowledge, attitude, and skills that contribute towards reducing the likelihood of adverse events and applying them to improve the quality of care delivered. This learning can take many shapes and forms, from formal training and education to on-the-job training or even something as simple as sharing best practices and experiences among healthcare professionals.
The goal here is to help healthcare providers identify risks and determine the best course of action to eliminate them, in turn, providing care that is as safe and effective as possible. This requires an ongoing commitment to monitoring, evaluating and addressing risk areas and using the knowledge gained to drive positive change.
There are various forms of learning that are relevant to patient safety, including:
Continuous Professional Development (CPD) - Designed to help improve subject matter expertise, this refers to the ongoing process of developing and enhancing skills, knowledge, and experience through activities and programs. CPD can take on various forms, including attending conferences, workshops, and training sessions, pursuing courses or certifications, research, coaching and mentorship, and more. This allows healthcare professionals to remain competent and knowledgeable in their field and stay up-to-date with the latest developments and best practices.
Root Cause Analysis (RCA) - Known as a systematic, problem-solving approach, RCA involves identifying and addressing the underlying cause(s) of adverse events to prevent them from recurring in the future. It is frequently used for learning and continuous improvement in patient safety.
Incident reporting - This is the process of documenting events such as medical errors, near-misses, equipment failures, medication mismanagement, and more to help healthcare providers identify areas for improvement and make changes to prevent similar incidents from happening in the future.
Healthcare workers have a responsibility to ensure the highest level of patient safety. By taking the time to be educated in the concepts of patient safety learnings and actively seeking opportunities for continuous professional development, together, these can positively impact patient outcomes and improve the delivery of care.
Patient Safety and the Benefits of ‘Learning’
Understanding and implementing learning in patient safety programs supports the goal of providing high-quality, safe, and effective care to patients through:
Improved Clinical Outcomes: By continuously learning and adapting to new practices and techniques, healthcare providers can improve patient outcomes and reduce adverse events. This is crucial in a fast-paced and rapidly evolving industry like healthcare.
Continuous Quality Improvement: Understanding and incorporating the learning process into patient safety programs promotes continuous improvement, enabling healthcare providers to identify areas of weakness and make necessary changes to ensure patient safety.
Improved Teamwork: Implementing learning into patient safety programs helps to enhance teamwork and collaboration among healthcare providers. This creates a supportive environment where providers can share knowledge, skills, and experiences to improve patient care.
Implementing ‘Learning’ in Patient Safety Programs
In the above sections, we've established that patient safety and learning from patient safety are crucial in healthcare. And while policies and procedures contribute to preventing harm, it just isn't enough. Organisations must also implement actionable initiatives to promote continuous learning and improve overall patient safety. Some ways to achieve this include:
1. Encouraging a culture of learning: The first and arguably the most fundamental step in implementing learning in patient safety programs is to promote a culture that values and encourages ongoing learning within your organisation.
There are many ways to do this, including providing staff access to training, workshops, online courses, and coaching programs, recognising and rewarding individuals committed to learning and development, providing opportunities for feedback, and encouraging staff to learn from the experiences of their peers and patients.
One of the goals of the LFPSE service is to promote a learning culture that doesn't villainize errors but instead looks at them as a unique learning possibility because understanding what went wrong and addressing it will prevent harm from reaching patients in the future. The mentality that errors are actually golden opportunities for learning will lead to improved patient safety down the line.
2. Identifying risks and root causes: To continuously improve patient safety and ensure that the same adverse event does not occur again, it is essential to identify the root cause.
This can be done by collecting all available information about the incident, using a structured approach to identify the contributing factors, using the "5 Whys" technique where you repeatedly ask 'why' until you reach the underlying cause, conducting a root cause analysis (RCA), regular patient safety audits, and feedback from patients and staff.
3. Promoting evidence-based practice: Evidence-based practice (EBP) in healthcare is a decision-making approach that integrates clinical expertise, patient values, and preferences with the best available evidence. By using this methodology, healthcare staff can make more informed decisions about patient care, in turn, improving care quality and boosting patient safety.
4. Investing in technology and tools: Technology and tools such as electronic health records, predictive analytics, and quality management software can help healthcare organisations track and analyse data on patient safety events. This information and technology can then be used as a learning resource to develop and implement targeted interventions to improve patient safety, measure impact, and further share learnings with the wider healthcare community.
Healthcare organisations can also use powerful tools like Lean Six Sigma to design processes and procedures that are more reliable and less prone to cause harm to patients, in turn, improving overall patient safety.
Today, organisations in high-risk industries like healthcare are already using the latest technology, such as AI and Machine Learning to identify and learn from event patterns, high-risk processes, and more to avoid preventable errors across their operations.
Conclusion
The importance of understanding and implementing learning in patient safety programs cannot be overstated. By fostering a culture of learning, identifying risks and root causes, utilising evidence-based practice, and investing in technology and tools, healthcare organisations can continuously improve patient safety and provide the best possible care to their patients.
By making learning and improvement a priority in their patient safety programs, healthcare providers will not only improve the quality of care they provide but also instil a culture of continuous improvement that will benefit their patients and their organisation for years to come.