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Proactive Risk Monitoring in Healthcare

PRIMO Phase 2 - Prerequisites for Deployment in Diverse Settings and the Impact on Safety Culture

Funded by the Health Foundation (2011 - 2013)



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 develop and to implement a local Proactive Risk Monitoring Tool 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 Safer Clinical Systems 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 most importantly to encourage active participation and ownership with clear feedback and demonstrable learning for local work practices. This tool should be of immediate relevance to practitioners and generate actionable learning from their experiences and expertise. The approach has been developed and piloted within the hospital dispensary during 2009.

  • First results were presented at the Patient Safety Congress 2010 in Birmingham.
  • A paper describing the PRIMO process has been published in BMJ Quality & Safety (MA Sujan, C Ingram, T McConkey et al., Hassle in the dispensary: Pilot study of a proactive risk monitoring tool based on narratives and staff perceptions).
  • A more comprehensive paper describing updated results of the PRIMO pilot as well as its impact on local safety-related attitudes and behaviours has been published in Reliability Engineering and System Safety (MA Sujan. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliability Engineering & System Safety 2012;101:21-34). Accepted version of the manuscript available for download (PDF Document).
  • The "upper" part of PRIMO, understanding how things go right and describing the resilient forms of behaviour that staff employ in order to deal with gaps and variations in the system, has been described in preliminary form in a paper presented at Human-Centred Processes 2011 (MA Sujan, S Pozzi, C Valbonesi, C Ingram. Resilience as Individual Adaptation: Preliminary Analysis of a Hospital Dispensary pdf_logo.jpg).
  • The final report of Phase 2 is now available for download (PDF Document)
  • Reflections on the PRIMO approach to reporting and organisational learning and other non-traditional approaches have been published in Clinical Risk (M Sujan and D. Furniss. Organisational reporting and learning systems: innovating inside and outside of the box. Clinical Risk 2015; 27th February (PDF Document)).
  • Staff broadly distinguish between two types of organisational learning processes, which can be described as "reporting formally" through incident reporting and "discussing informally" with line managers, peers and colleagues from other departments. A paper exploring staff attitudes towards reporting and learning has been published in Reliability Engineering and System Safety (M Sujan. An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. Reliability Engineering & System Safety 2015;144:45-52). Open Access.

Phase-2 Aims

PRIMO Phase 2 runs from 2011 - 2013 involving two additional NHS organisations. The aims of PRIMO-2 are:

  • To determine prerequisites for successful implementation of PRIMO across diverse settings, and to assess whether PRIMO leads to actionable learning in those settings.
  • To evaluate to what extent and through which mechanisms participation in PRIMO encourages a stronger, inclusive safety culture.


The project employs a multi-disciplinary mixed methods approach, consisting of implementation case studies, qualitative and quantitative elements. The work is organised into three work streams as follows:

  • WP1 (Implementation Case Studies) sets up the four study environments and implements and runs the PRIMO process in each environment over a period of time. Implementation diaries will be kept at each organisation and together with interviews with key staff these will be used to qualitatively describe prerequisites for successful implementation across diverse settings. Key staff will also be interviewed to assess the extent to which they perceive that PRIMO has contributed to actionable learning within their environment. This will be complemented by quantitative findings from a survey administered to all staff who participated in PRIMO.
  • WP2 (Impact on Safety Culture) aims to qualitatively describe changes in relevant safety-related attitudes and behaviours of staff and to identify possible mechanism through which these came about. Interviews will be conducted with staff at each site before and during the implementation of PRIMO. The interviews will be coded according to the framework developed as part of the PRIMO pilot at Hereford.
  • WP3 (Recommendations) brings together the findings of the previous work packages to provide recommendations for the adoption of proactive risk monitoring as a tool for organisational learning in the NHS.


The final report is available for download (PDF Document).

  • A poster (PDF Document) describing experiences of running PRIMO within the Surgical Admissions Unit at Lincoln Hospital was displayed at the Patient Safety Congress 2013 in Birmingham.
  • Two junior doctors who are part of the team at Lincoln will gave a presentation about their experiences at the NACT Foundation Programme Sharing Event in June in London.
  • A brief update about ongoing work at Lincoln was published online in the BMJ as rapid response (Rees, Whitton, Marsh, Sujan. Proactively improving patient safety).

Project Team

Mark-Alexander Sujan (PI)

Matthew Cooke

Sharon Pickering