last review, which we will strive to apply to the currently identified theme in this review period.
Incident Rates: The proportion of significant or serious incidents remains low relative to the volume of patient contacts, indicating a continued positive trend in patient safety. For example, the EA service reported 4 incidents from 13,698 patient contacts (approx. 0.03%), and GPFD
Service QEH reported 1 incident from 38,262 patient contacts (approx. 0.003%). This compares with the previously audited period, where the EA service reported 8 significant events from approx. 8,000 patient contacts (approx. 0.1%) and GPFD Service JPUH reported 4 significant events from having 35,792 patient contacts (approx. 0.01%). These findings reflect our continued commitment create a culture of delivering safe care and learning across all services.
Robust management oversight of reported incidents is maintained at all levels. The Quality & Safety Committee oversees the reporting structure, with monthly performance scorecards submitted to the Board. Weekly service-level reviews of reported incidents enable real-time discussion, learning, and implementation of improvements. Comprehensive investigation reports are produced for all patient safety incidents and submitted to both the Quality & Safety Committee and the Board for review and oversight, with collaborative sharing of the investigation into incidents with external parties and stakeholders, where appropriate. In the period of 1 st April 2024 to 31 st March 2025, we received, investigated, and applied outcomes learning to the following number of recorded events:
When the total number of reported events received, 108 , is set against the circa 184,010 patient contacts across all our services, it equates to a 0.06% SI/SE to patient contact ratio, which demonstrated a relatively very low SE/SI volume (compared to a ratio of 0.04% in the 2023/24 period).
Accident & Incident:9 8%
Serious Incident:4 4%
Safeguarding Incident:2 2%
Significant / Learning Event:93 86%
NPC’s approach to managing complex and high-risk patient safety incidents is currently governed by its Significant Event and Serious Incident Policies. These policies have provided a structured
Norfolk Primary Care - Quality Account 2024/25
39 | Pa g e
Made with FlippingBook - Online catalogs