A structured annual thematic analysis was undertaken across the Patient Safety Incident (PSI) dataset. Incidents were systematically reviewed and grouped according to shared characteristics, contributory factors, and contextual themes. The analysis considered a range of domains including:
• Communication and information sharing • Documentation and record keeping • Clinical assessment and decision-making • Capacity, staffing, and workload pressures • Systems, pathways, and interface challenges • Equipment, environment, and digital systems
Themes were refined through an iterative process, with patterns and frequencies reviewed across services and incident types. Both actual harm and potential risk were considered to support a proportionate, risk-based prioritisation approach Key Findings from the PSI Thematic Review A total of 103 incidents were categorised across several themes, highlighting key areas for improvement and organisational learning. The largest proportion of incidents ( 62 ) related to Clinical Care. These primarily involved delays in patient assessment or clinical review, incomplete examinations, and failures to follow up abnormal results. Additional concerns included delayed escalation of deteriorating patients and inconsistent application of clinical guidance. There were 21 incidents associated with Policy, Procedures and Processes. These reflected unclear or inconsistently applied policies, issues within referral and triage processes, variation between services, and gaps in effective handover or follow-up arrangements. A further 11 incidents were linked to Medicines Management and Prescribing. Key issues included incorrect prescribing, delays or omissions in medication provision, inadequate monitoring of high- risk medicines, and communication challenges between care settings. Administration-related incidents accounted for 4 cases. These included appointment booking errors, delays in processing referrals and results, and inaccuracies in patient records that impacted continuity of care.
Norfolk Primary Care - Quality Account 2025/26
40|Page
Made with FlippingBook - PDF hosting