Spotlight Project – Patient Safety in Primary Care

Principal / Lead investigator
Co-investigators / research team
Type of study

Development of an educational programme


There is a major opportunity to accelerate efforts to stimulate national and international thinking on primary care safety. Between 2-3% of primary care consultations result in unsafe care. Given developed nations demonstrate up to 90% of healthcare encounters can be delivered in primary care, this represents a major, overlooked, public health issue. 

Internationally, the World Health Organization’s Universal Health Coverage agenda is predicated on the provision of primary care services. Many countries (mostly low and middle income countries) will be seeking to emulate the successes of established primary care-led healthcare systems. The NHS must now endeavour to examine the safety of its primary care services and share the lessons learnt. 

The PISA Group has completed a major NIHR funded study to describe the safety incident reports written by primary care professionals, and has now read over 50,000 reports. The priority areas for improvement in primary care, based on the experiences of healthcare professionals reporting unsafe healthcare; the “PISA STUDY” has now been published: http://www.nets.nihr.ac.uk/projects/hsdr/1264118

Identifying what goes wrong, and the probable underlying causes, is an important first step to begin to conceptualise how future care can be improved and delivered safely. 

Learning from several decades of improvement initiatives in hospitals highlights the workforce must have the quality improvement (“QI”) knowledge and skills to improve healthcare to achieve better patient outcomes, better system performance, and better professional learning. Experts responsible for the design and delivery of QI educational programmes advocate engaging.

Lay involvement

During the initial set up phase, we will co-produce a formal training package with the three lay advisors located in Yorkshire and Wales to support them in delivering the health check. We envisage that this will involve a face-to-face training session and manual (including technical aspects and practical interactive activities to help lay advisors understand and apply the behaviour change concepts underpinning the health check), with ongoing supervision and support throughout the trial. Lay advisors will be located with their respective charity (Yorkshire Cancer Research or Tenovus Cancer Care) and partnered with a relevant local support network (eg UKCRN).

Who is the study sponsor?

Cardiff University

Does the study involve commercial partnership activity?



RCGP Spotlight Award

Total grant value

£ 60,000

Grant income to Wales

£ 51,500

Start date


End date


How could this research potentially benefit patients?

The project could lead to improvements in cancer awareness in deprived communities.

Further information

News: New clinical spotlights and projects announcement, RCGP News, March 2016

Presentation slides: Breathing life into patient safety incident reporting, March 2017

Outputs generated (Reports / Publications / Impact)

This project is developing, certifying and disseminating e-learning modules to support GPs and GP trainees to learn about QI and demonstrate how to apply QI in practice.

The content has been empirically informed by the priority issues identified in the PISA STUDY and include real-life re-enacted filmed scenarios from England and Wales.

It is envisaged the modules will be included in the appraisal / validation / trainee portfolio system.

The patient safety in primary care course is now available on the Royal College of General Practitioners e-learning site (accessible to all): http://elearning.rcgp.org.uk/course/search.php?search=patient+safety+in+primary+care