3.6 Incident Reporting and Learning Following on from our commitment to fully embed patient safety in our culture, it is reflected in the maturity and robustness of our governance frameworks, which support effective clinical oversight, accountability, and continuous learning. During the 2024/25 period, Norfolk Primary Care (NPC) began the journey of implementing the Patient Safety Incident Response Framework (PSIRF), marking a significant shift in how we report, investigate, and learn from incidents. This has supported a more proactive and transparent process and built on our learning-focused approach to patient safety across the organisation.
Our incident management processes prioritise openness, honesty, and respectful communication - ensuring patients and staff are fully supported and remain central to all responses. This approach continues to foster trust, strengthen our safety culture, and drive continuous improvement. To complement our current PSIRF implementation journey and moving into the 2025/26 period, we conducted a thematic review of historical incidents, and the methods used to investigate them to understand which areas may need improvement or development.
This review identified key areas for system and process improvement to help reduce recurrence and enhance organisational learning. It also highlighted meaningful progress in staff engagement. We have historically fostered a ‘no blame’ culture that encourages reporting and learning from those highlighted concerns and will now focus on adopting the NHSE ‘Being Fair’ tool alongside the PSIRF principles. This is further supported by improved channels for patient feedback, including surveys and clearer guidance on how to raise concerns or complaints.
Key Findings from the Thematic Review Patient Care Themes: Prescribing-related incidents emerged as the most common type of reported safety event during this period. Notably, referral delays - previously identified as a common issue in the 2023/24 audit - were no longer an identified theme. This suggests effective learning and process improvements have been implemented since the
Norfolk Primary Care - Quality Account 2024/25
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