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Introduction
Incident reporting is a key mechanism for organisational learning in the NHS and has received a large amount of attention during the past 10 years. 1-3 In addition to many local incident-reporting systems, the National Patient Safety Agency operates a National Reporting and Learning System to identify risks and opportunities to improve patient safety across the NHS. There has been considerable research into barriers to reporting, such as lack of training in the use of incident reporting, usability problems of the systems that have to be used, uncertainty about what constitutes a reportable incident, blame culture and fear of consequences, lack of feedback and the absence of learning relevant to local practices. 4-8
In 2008, the Health Foundation commissioned the Safer Clinical Systems (SCS) programme involving four NHS organisations to develop systems approaches to delivering more reliable and safer care. At Hereford Hospital, one of the aims of their SCS work was to prototype and to implement a local Proactive Risk Monitoring System for Organisational Learning (PRIMO) to complement incident reporting. The project aim was the result of a very practical need: very few incident reports were available at the start of SCS, and the learning that could be extracted from these in terms of error-producing conditions and latent factors was minimal. The PRIMO approach is intended to operate alongside incident reporting, but its aim is to elicit a rich contextual picture of the local work environment, to move away from negative and threatening notions of errors and mistakes, and to encourage active participation and ownership with clear feedback and demonstrable learning for local work practices. The system was prototyped and piloted as a service improvement project within the dispensary of the hospital pharmacy, and the paper describes the principles of the system and the results of the pilot.
Intervention overview: PRIMO
The PRIMO system consists of a number of elements: staff narratives, questionnaire and action plan. Staff narratives are used to identify empirically a set of Basic Problem Factors for subsequent monitoring to ensure that these factors are relevant to the local work environment. Monitoring takes place using a questionnaire to elicit perceptions from staff about the amount of hassle that these factors cause to their daily work in order to construct a...