This article outlines the new features of LFPSE Version 6:
Separate Forms
Instead of having 1 LFPSE form that contains all Incident, Good Care, Outcome, Risk and Governance questions, there are 5 separate forms:
- LFPSE – Incident
- LFPSE – Good Care
- LFPSE – Outcome
- LFPSE – Risk
- LFPSE – Governance (Only relevant for Incident LFPSE events)
Guidance Text
It is mandatory to add the LFPSE Guidance text to appear in the event drop down list to help users select the right event option:
| Event Option | LFPSE Guidance Text |
| Incident | Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm |
| Good Care | An example of good care that can be learned from |
| Risk | A risk to patient safety in the future, though no patients have yet been affected |
| Outcome | A poor outcome routinely reported locally where it is not yet known whether or not the outcome was caused by a patient safety incident |
Data Submission
Whenever the LFPSE form is filled in, the data will submit to NHS England. This didn’t used to be the case if the question “Does this event involve a patient?” = NO.
This will be changing from the end of 2024 and a new question will be available to add to the LFPSE for to determine if data is submitted: “Enable LFPSE Submission”.
Disable Save For Later
Forms that contain LFPSE questions will not have the option to ‘Save For Later’. These forms must be ‘Saved and Completed’ to ensure LFPSE has real-time data.
DM+D List
NHS Dictionary of Medicines + Devices has been added to the form. This can also be used in other forms in your system. More info here:
New Enhanced Custom Lists
There are 3 new Enhanced Custom Lists that populate drop down lists in the LFPSE form. These lists are maintained by Radar Healthcare.
| Enhanced Custom List Name | Question Populated |
| Primary location type | Where did the incident happen? |
| Primary service | Which service types were involved? |
| Primary speciality | Which speciality does the incident relate to? |
Location Benchmarking Fields
It is possible to populate default responses to some LFPSE questions based on new ‘Bench-marking’ fields within Location settings. More info here:
Question Updates
New Questions
| LFPSE Forms Affected | Question |
| Incident | Which of these best describes your role? |
| Incident | What was your role in relation to the incident? |
| Incident | Was a device used to give medication in this instance? |
| Incident | What kind of IT system or software was involved in what went wrong? |
| Incident | Who manufactured the IT system or software? |
| Incident | What was the version number of the IT system or software? |
| Incident | If you have already reported this issue direct to the IT system or software supplier, please include any reference numbers here |
| Incident | Was the availability of staff a factor in this incident? |
| Incident | Did people's activities differ from what was expected or intended? |
| Incident | What was the problem with the activities? |
| Incident | What is the patient's gender? |
| Incident | Is the patient's gender identity the same as the sex they were registered with at birth? |
| Incident | Which stage or process of care delivery was being undertaken at the time of the event? |
| Governance | Which incident framework is your organisation operating under? |
| Governance | Is there a national or regulatory requirement to conduct an investigation in response to this event? |
| Governance | How will you respond? |
| Governance | Confirm how you responded |
| Governance | Findings |
| Governance | What areas for improvement have been agreed as a result of this response? |
| Governance | Have safety actions been developed? |
| Governance | What safety actions have been made to address this area for improvement? |
| Governance | How will areas for improvement be addressed (e.g. wider review)? |
Removed Questions
| LFPSE Forms Affected | Question |
| Incident | What was wrong with the drugs used |
| Incident | Do you think any of the below were relevant to the incident occurring? |
| Incident | What was the patient's age (in days) at the time of the event? |
| Incident | What is the patient's sex? |
| Incident | Has the incident been discussed with the Patient / Next of Kin? |
| Incident | Please summarise the Patient and / or Family's feelings or experience discussed during the conversation |
| Incident | Why has the discussion not taken place? |
Question Wording Amendments
| LFPSE Forms Affected | Question |
| Incident | Old Wording: Does this incident involve a patient(s)? New Wording: How many patients were affected? This question is changing from a yes/no question to a drop down question. |
| Incident | Old wording: What was the model or serial number of the device? New wording: What was the model of the device? |
| Incident | Old wording: Please specify other drug involvement New wording: What was the problem with the medication? |
| Incident | Old wording: Which of the following were involved? New wording: Which of the following buildings or infrastructure were involved? |
| Incident | Old wording: Please specify other buildings infrastructure involvement New wording: What was the problem with buildings or infrastructure? |
| Incident | Old wording: Which of the following were involved? New wording: Which of the following estates services were involved? |
| Incident | Old wording: Please specify other area where blood was involved New wording: What was the problem with the blood? |
| Incident | Old wording: How were blood products involved in an unexpected way? New wording: How were blood products involved in what went wrong? |
| Incident | Old wording: Please specify other area where blood products were involved New wording: What was the problem with the blood products? |
| Incident | Old wording: Please specify other tissue and organs for transplant involvement New wording: What was the problem with tissues or organs for transplant? |
| Incident | Old wording: Please supply the NHSBT Report Number New wording: NHS Blood and Transplant report number |
| Incident | Old wording: How was people's availability involved in what went wrong? New wording: How did staff availability affect the event?
|
| Incident | Old wording: Why were required people absent? New wording: Why were the required staff not present? |
| Incident | Old wording: Which people's actions differed from what was expected or intended? New wording: Which people's activities differed from what was expected or intended? |
| Incident | Old wording: How did people's actions differ from what was expected or intended? New wording: How did activity differ from what was expected or intended? |
| Incident | Old wording: How did people do something too much? New wording: How was too much activity undertaken? |
| Incident | Old wording: How did people do something too little? New wording: How was too little activity undertaken? |
| Incident | Old wording: How did the wrong action get taken? New wording: How did activities differ from what was intended? |
| Incident | Old wording: Why wasn't the right action taken? New wording: Why did activities differ from what was intended? |
| Incident | Old wording: What was the clinical outcome for the patient New wording: How did this impact the patient and their subsequent care? |
| Incident | Old wording: What was done immediately to reduce harm caused by the incident? New wording: What immediate actions were taken to reduce harm to the patient(s)? |
| Incident | Question: How were IT systems or software involved in what went wrong? Options: Can now select multiple. |
| Governance | Old wording: Indication of whether the adverse event meets the requirements for duty of candour New wording: Does this qualify as a notifiable safety incident under the Duty of Candour regulations? |
Question Option Amendments
| LFPSE Forms Affected | Question |
| Incident | Question: Reworded options: ‘Screening services incident’ changed to ‘NHS screening programme incident’ New options: Treatment Delay
|
| Incident | Question: Which things were involved in the incident? Reworded option: ‘Blood’ changed to ‘Whole blood or Blood components’ |
| Incident | Question: How was the device used when it should not have been? Reworded option: ‘Too many devices were used/The device was not required’ changed to ‘The device was used when it should not have been’ |
| Incident | Question: Which of the following processes were involved in what went wrong? Reworded options: ‘Prescription’ changed to ‘Prescribing’ ‘Administering’ changed to ‘Administration’ New options: ‘Advice relating to medicines use’ ‘Supply from a clinical area’ ‘Security and storage’ |
| Incident | Question: What kind of medical device was involved in what went wrong? Reworded option: ‘Anaesthetic and airway devices and breathing masks and tubing’ changed to ‘Airway devices and breathing masks and tubing (including those used in anaesthesia)’ |
| Incident | Question: How were the tissue and organs for transplant involved in what went wrong? Reworded option: ‘Tissues or organs for transplant were available but damaged’ changed to ‘Tissues or organs for transplant were available but damaged or unfit for use’ |
| Incident | Question: How did staff availability affect the event? Reworded options: ‘There were too many people involved’ changed to ‘Too many staff involved’ ‘There were people absent who were required’ changed to ‘Required staff not present’ ‘The wrong skill mix was involved’ changed to ‘Wrong skill mix’ |
| Incident | Question: Why were the required staff not present? Reworded options: ‘People's arrival was delayed’ changed to ‘Staff's arrival was delayed’ ‘People were called away/had to leave too soon’ changed to ‘Staff's were called away/had to leave too soon’ ‘There was a shortage of available people’ changed to ‘There was a shortage of available staff’ |
| Incident | Question: How did activity differ from what was expected or intended? Reworded options: ‘People did too much of something<’ changed to ‘Too much activity was undertaken’ ‘People did too little of something’ changed to ‘Not enough activity was undertaken’ ‘People did one thing when they meant to do another’ changed to ‘Different activity than intended was undertaken’ ‘People did not do something they should have’ changed to ‘Activity that should have been undertaken was not’ |
| Incident | Question: How did activities differ from what was intended? Reworded options: ‘One action was taken in place of another’ changed to ‘One activity was undertaken in place of another’ ‘A wrong action was taken as well as the right one’ changed to ‘An incorrect activity was undertaken as well as the correct one’ ‘The right action was only partially completed’ changed to ‘The correct activity was only partially completed’ |
| Incident | Question: Why did activities differ from what was intended? Reworded options: ‘People did not know the right thing to do’ changed to ‘People did not know the correct thing to do’ |
| Incident | Question: When was the Event identified? Reworded option: ‘Proactive risk assessment undertaken during design of a new service or significant redesign of an existing service’ changed to ‘Proactive risk assessment during service design or redesign’ |
Guidance Text Added / Amended
| LFPSE Forms Affected | Question |
| Incident | Question: Describe what happened Guidance added: Include details of anything you think was important, or might help us learn from what happened. Avoid including any identifiable information such as names of staff or patients here. The national patient safety team focus their primary learning activities on the information provided here, so a full description and sequence of events will contribute to better learning and improvement. Please see here for further details on how we use patient safety event data - https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/ |
| Incident | Question: Does the incident appear to relate to any of these known national safety challenges? Guidance added: This list is used to identify those incidents which relate to national programmes of work; though all events are used to contribute to national learning. Your answer should be based on the information you have at this point, and can be changed if further information becomes available. |
| Incident | Question: Does the incident appear to relate to any of these known national safety challenges? Guidance added: Safety incidents and serious incidents that occur in the delivery of an NHS screening programme should be notified to the regional Public Health England Screening Quality Assurance Service (SQAS) and to the regional NHSE commissioner. Please refer to national guidance for information. Further advice can also be obtained from PHE's national screening helpdesk who can be contacted on 020 3682 0890 or via the online form. If you know that this event has been reported to SQAS and the NHSE commissioners, please include the Marvin reference number in the field below to enable linkage. |
| Incident | Question: Which things were involved in the incident? Guidance added: Your answer should be based on the information you have at this point. These options act as a trigger for subsequent more detailed questions required by our national patient safety data partners (e.g. MHRA, estate services etc). |
| Incident | Question: Which things were involved in the incident? = Buildings or Infrastructure Info displayed: Buildings or infrastructure. Click here for examples:
|
| Incident | Question: What kind of medical device was involved in what went wrong? Guidance added: Start typing and select the relevant device from the list. |
| Incident | Question: Please supply the SHOT Report Number Guidance added: Under the Blood Safety and Quality Regulations (2005 as amended) blood and blood component Serious Adverse Events (SAE) and Serious Adverse Reactions (SAR) are legally required to be reported to the Medicines and Healthcare products Regulatory Authority (MHRA). The Serious Hazards of Transfusion (SHOT) is the UK's independent, professionally led haemovigilance scheme, collecting and analysing anonymised information on adverse events and reactions in blood transfusions from all healthcare organisations in the United Kingdom. The MHRA and SHOT have collaborated to improve haemovigilance reporting by producing an integrated incident reporting process through the Serious Adverse Blood Reactions and Events (SABRE) platform. All SAR and SAE incidents related to the safety and quality of blood must be reported through your local hospital blood bank or blood establishment SABRE representatives. If you know that this patient safety event has been reported to the MHRA and SHOT, please include the SABRE/SHOT report number(s) for linkage. |
| Incident | Question: Please supply the Sabre Report Number Guidance added: Please supply the SABRE Report Number" inlineText="Under the Blood Safety and Quality Regulations (2005 as amended) blood and blood component Serious Adverse Events (SAE) and Serious Adverse Reactions (SAR) are legally required to be reported to the Medicines and Healthcare products Regulatory Authority (MHRA). The Serious Hazards of Transfusion (SHOT) is the UK's independent, professionally led haemovigilance scheme, collecting and analysing anonymised information on adverse events and reactions in blood transfusions from all healthcare organisations in the United Kingdom. The MHRA and SHOT have collaborated to improve haemovigilance reporting by producing an integrated incident reporting process through the Serious Adverse Blood Reactions and Events (SABRE) platform. All SAR and SAE incidents related to the safety and quality of blood must be reported through your local hospital blood bank or blood establishment SABRE representatives. If you know that this patient safety event has been reported to the MHRA and SHOT, please include the SABRE/SHOT report number(s) for linkage. |
| Incident | Info text: Everyone involved in organ donation and transplantation wants to ensure that transplanted organs are as safe as possible for all transplant recipients. Under the Quality and Safety of Organs Intended for Transplantation Regulations, any incident that has any undesired, unintended and/or unexpected occurrence associated with any stage of the donation to transplantation pathway that might lead to the transmission of a communicable disease, to death or life-threatening, disabling or incapacitating conditions for patients or which results in, or prolongs, hospitalisation or morbidity must be reported to NHS Blood and Transplant. https://safe.nhsbt.nhs.uk/IncidentSubmission/Pages/IncidentSubmissionForm.aspx If you know that this event has been reported to NHSBT, please provide the NHSBT report number to enable linkage. |
| Incident | Question: How concerned are you about this event and its implications? Guidance added: Indicate the impact on the safety of healthcare overall, and/or to what extent others may not be aware that this issue exists. Your answer should be based on your own judgement, given the information you have at this point, and can be changed if further information becomes available. Your personal perspective on this is valuable. This question is being trialled by the national Patient Safety team to explore whether it can help point to incidents which enable proactive national action, alongside the reactive responses to the most severe harms. |
| Incident | Question: How much did the incident contribute to the outcome for the patient? Guidance added: Your answer should be based on your own judgement, given the information you have at this point, and can be changed if further information becomes available. Your personal perspective on this is valuable. This question is being trialled by the National Patient Safety team to explore whether it can help prioritise incidents with the greatest opportunities for learning." |