PRIMO

In brief

The National Patient Safety Agency (NPSA) was set up to tackle the issue of patient harm through systems failure in 2000 and created the National Reporting and Learning System (NRLS), an incident reporting system designed to identify risks and reduce them before an accident or adverse event takes place. But incident reporting is not as effective as it could be due to staff pessimism about lack of positive change, the culture of error being perceived as threatening, and because an incident reporter may not know why the incident happened if the causal factors took place earlier on in the patient journey with different staff.

PRIMO began as a project in our Safer Clinical Systems (SCS) programme (which seeks to identify and reduce risks to patient safety). The team at Hereford dispensary co-designed an innovative risk assessment process to complement current incident reporting protocol. ‘Proactive Risk Monitoring in Healthcare’ (PRIMO) allows an organisation to assess the amount of control it has over processes such as communication or training that often create weakness in the system (latent conditions), and can contribute to adverse events. People make mistakes however how hard they try, but latent conditions are the result of organisational deficiencies that are under our control, and can therefore be changed. 

PRIMO encourages front line staff to own this process, and aims to create a stronger safety culture. It uses narratives, a questionnaire, a visible action plan and the concepts of safety space and safety time to create a risk profile and engage staff in a positive action plan for safety improvement.

From June 2009 to December 2010 the PRIMO process was co-designed and tested in the dispensary at Hereford.

We are now preparing to implement and test the PRIMO tool more widely in four diverse healthcare settings. This work will focus on identifying key factors for successful implementation, refining the tool and assessing the impact of the tool on staff.

The programme is funded by the Health Foundation with technical support provided by Mark-alexander Sujan at the University of Warwick.