PrescQIPP

Shared learning from medication safety events (2025)

NHS Birmingham and Solihull ICB

Project summary

In 2022 the National Reporting and Learning System (NRLS) was retired, but its replacement, ‘Learn From Patient Safety Events’ (LFPSE) is not yet embedded in primary care. We knew there was low reporting of patient safety events in primary care; in 2021 less than 1% of the 2.2 million reports received by the NRLS each year were from primary care (NHSE).

The Birmingham and Solihull (BSol) ICB Medicines Management and Optimisation (MMO) Team produced and implemented a ‘shared learning’ project in primary care in 2024/25. As part of the BSol local incentive scheme in 2024/25, every practice committed to identify a medicines safety event and to discuss it at a meeting facilitated by an MMO pharmacist. The specification also required an anonymised copy of the event to be submitted to the ICB Medication Safety Officer, to enable a system wide review for themes and learning that, if shared, could mitigate risk of future events. The project aimed to:

  • equip members of the primary care general practice team with the skills to improve patient safety through effective investigation of patient safety incidents involving medicines
  • encourage a culture that focuses on the role of systems, not individuals, when things go wrong, and a systems approach to solutions and compassionate leadership, encouraging practice staff to learn without fear of retribution.
  • encourage reporting at a time where the national and local emphasis on this was focussed in secondary care,
  • share learning from practice review of anonymised reports within the system to inform practice and system changes to mitigate future risk.

To ensure effective facilitation, the MMO team received education on patient safety, investigating safety events and systems thinking. A briefing document was produced to support delivery and signpost to relevant national and local patent safety information. A standard form for returning an anonymous record of discussions was provided.

Discussions in practices included a wide range of staff, including clinicians, reception staff, prescription clerks and other stakeholders. Following a thorough investigation of the event, the MMO team member in each practice collated an anonymised summary and submitted this to the ICB Medication Safety Officer. Working with a Senior Technician, 176 reported events were logged, tagged and collated into themes. They were discussed at a task and finish group and agreed learning was shared in a number of ways including via communications, e.g. newsletters, and educational webinars. The team also promoted the use of LFPSE for future reporting. 

The learning from this project has also informed a wide range of ICB workstreams, including pathway development, formulary monograph changes, collaboration with provider trusts, a DOAC safety review and development of a new project incorporating the RPS/RCGP Repeat prescribing Toolkit. We intend to continue to share learning from these events regularly in the monthly ICB medicines newsletter over the next year to keep reporting medication safety events at the forefront of the minds of clinicians and practice staff.

While it is difficult to quantitatively assess the impact of this intervention on the safety of patients in Birmingham and Solihull, we know that safety culture has been a key and recurring theme in reports where there has been poor care. Creating a positive safety culture and using the information shared to inform interventions should improve both patient safety and provide savings for the NHS.