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Exemplar project: NHS Patient Safety Incident Management System

Informed Solutions’ national project to reduce the number of patient safety incidents in the NHS has been highlighted as an exemplar of how SMEs can meet the requirements of major public sector organisations.


The project has been recognised by techUK, the leading association of tech sector employers, as an exemplar of how SMEs can meet the digital transformation requirements of major public bodies such as the NHS. Informed Solutions’ Technical Director, Matt Rix, is delighted to showcase this ‘tech-for-good’ project which will help to reduce the number of patient safety incidents in the NHS.

The new national Patient Safety Incident Management System, currently in Private Beta, will support data collection from a wide range of healthcare providers, including 7,450 GP Practices (seeing 1m patients every 36 hours), 135 acute trusts (delivering 10+m procedures & interventions annually), dentists, and pharmacies, and will integrate this information into a national system.

Once collected and validated, innovative Artificial Intelligence (AI) and Machine Learning technologies will be combined with expert clinical review to optimise data analysis and improve the capability of the NHS to learn as much as possible from the data collected and feed these insights into improved practice.

The new system replaces a forerunner which used manual clinical review analysis only and routinely interrogated less than 5% of the available data. The new system will interrogate up to 100% of incidents. 

Co-Design, Co-Location & Collaboration

A fundamental principle of the project was ensuring the core team of NHS Improvement and Informed Solutions staff formed a collaborative, co-located unit to engage with a wider stakeholder group, comprising over a thousand NHS staff, national policy-makers, patients and members of the public:  in total, a network of nearly 1,500 engaged users to ensure ‘fitness for purpose’!

This close collaboration is essential to design of the service, ensuring on-going feedback, establishing advocates for the new service and building readiness for implementation at national scale.

One of the key features of the new service, identified during the research, is making it easy for stakeholders – organisations uploading data to the system, clinicians, academics – to access the data, thereby rewarding their contribution and ensuring maximum benefit is derived from the data, supporting an increase in successful safety interventions and knowledge-sharing prompted by increased data insights.

The system is being built using an Agile approach, and designed to meet the exacting Government Digital Service standards, the benchmark for public-facing digital services, with the Alpha assessment passed at the first attempt.

The core team of around 20 NHS Improvement clinical and policy staff and Informed Solutions’ specialists maintain progress and direction via daily ‘stand-ups’ to update each other, hold reviews of progress at the end of each 2-week phase of work (‘sprint’) and brief the wider stakeholder group via fortnightly ‘show & tell’ sessions.

No pain, only gain

The anticipated benefits of the new system, currently being trialled with around 20 organisations prior to national roll-out, are as wide-ranging as they are significant. They include rapid identification of new or under-recognised patient safety issues, automated trend identification to allow targeted improvement activities, supporting high-quality investigations, ensuring the right incident records and analyses are seen by the right people, and fast-tracking the ability of the NHSI Patient Safety Team and others to intervene.

In turn, those moves will mean a reduction in the number of incidents and in the costs of care and associated litigation. Gains measured in hard cash will be set alongside qualitative improvements such as improved quality of care for patients, improved experience for family members and dependants and, last but by no means least, increased staff morale as the impact of the learning from the incidents staff have taken the time to share becomes clearer.

A step-change in the reduction of patient safety incidents is within reach!

For further details of the project, go to:

Matt Rix, Technical Director at Informed Solutions & Project Lead
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