LFPSE: Patient Safety Incident Reporting in Community Pharmacy

About this service

The Learn from Patient Safety Events (LFPSE) service is the national NHS system for recording and analysing patient safety events. It replaced the National Reporting and Learning System (NRLS), which was decommissioned on 30 June 2024. Any pharmacy that was previously reporting to NRLS must now use LFPSE.

LFPSE forms part of the NHS patient safety framework. Pharmacies should ensure incidents involving NHS services are reported appropriately through the correct LFPSE route, and should follow any organisational policies that cover private services, which may have separate governance arrangements.

Understanding LFPSE requires clarity on three distinct obligations that are often confused:

1. Patient safety incidents that caused harm, could have caused harm, or identify a significant patient safety risk should be reported to LFPSE.
2. Routine dispensing near misses (errors caught before reaching the patient) are normally recorded internally for learning rather than reported to LFPSE.
3. Every pharmacy must maintain an internal incident and near miss log, regardless of whether events are reportable to LFPSE.

Reporting an incident to LFPSE does not replace urgent clinical action, local escalation procedures, Controlled Drug reporting requirements, safeguarding duties, or duty of candour obligations where these apply.

Controlled Drug incidents deserve particular attention. CD dispensing errors, missing stock, balance discrepancies, and destruction errors may require escalation beyond LFPSE through local Controlled Drug governance arrangements and the Controlled Drugs Accountable Officer process.

NHS England analyses LFPSE data and publishes aggregated quarterly reports to support safety learning. Individual pharmacy data is not published publicly, but is accessible to commissioners, Integrated Care Boards, and regulators including the GPhC.

How to deliver the service

1. Ensure your pharmacy has a LFPSE reporting route Community pharmacies must have access to a route for reporting patient safety incidents to LFPSE, either directly or through an organisational process. Most independent pharmacies and smaller groups report directly: go to record.learn-from-patient-safety-events.nhs.uk and set up an account using your NHS email address and ODS code. If you already have an NHS England Applications account, use those credentials. Large multiple pharmacy groups may report through a central governance structure or Local Risk Management System (LRMS) linked to LFPSE: check with your Superintendent Pharmacist or head office if you are unsure which route applies. Ensure appropriate admin account access exists so reporting can be maintained even when key staff are absent.
2. Maintain an internal incident and near miss log LFPSE does not replace the pharmacy's internal incident log. Every pharmacy must maintain its own record of all patient safety incidents and near misses. Near misses are especially valuable: they reveal systemic risks before harm occurs and are the most actionable source of safety information available to a pharmacy team. The internal log is also what the GPhC will examine during an inspection to assess learning culture, and it is where patterns and trends across multiple incidents will become visible.
3. Identify whether an event is reportable to LFPSE Report to LFPSE any event that caused harm to a patient, could have caused harm, or that identifies a significant patient safety risk. Routine near misses (errors caught during the accuracy check) are normally recorded internally. If you are unsure whether a specific event should be reported to LFPSE, seek advice from your governance lead or Superintendent Pharmacist. When uncertainty remains, reporting is generally preferable to under-reporting. Controlled Drug incidents may require additional reporting through local CD governance arrangements and the Accountable Officer process, regardless of whether they also trigger an LFPSE submission.
4. Take immediate action, then submit the event to LFPSE Submitting to LFPSE is never the first priority. Before reporting, ensure: the patient is protected from further harm, any urgent clinical intervention has been considered and arranged where needed, and the pharmacist or manager has been informed. Incidents involving high-risk medicines (insulin, methotrexate, anticoagulants, and other high-alert medicines) may require same-day clinical follow-up with the patient or their prescriber regardless of the LFPSE report.\n\nWhen recording the event in LFPSE, describe what happened clearly and factually. Avoid entering unnecessary patient-identifiable information (name, NHS number, address) in free-text fields. Follow local information governance requirements. Do not include staff names in descriptions: LFPSE is a learning system, not a disciplinary tool.\n\nSubmit the event as soon as practicable: delayed reporting reduces accuracy.
5. Conduct a proportionate local learning review Every patient safety incident should be considered for learning. The depth of review should be proportionate to the severity, complexity, and recurrence risk of the event. A minor single error may need only a brief team discussion. A moderate or severe harm incident, or a pattern of repeated near misses, warrants a structured review involving root cause analysis, documented findings, and agreed changes.\n\nThe GPhC expects to see evidence that: incidents are reviewed, trends are monitored, learning is shared with staff, and actions are followed up. Pharmacies that can only show a log of submitted LFPSE events without evidence of learning and improvement are not meeting the spirit of the clinical governance requirement.\n\nIncident trends should be reviewed periodically through the pharmacy's clinical governance processes, and recurring risks escalated to the Superintendent Pharmacist or organisational governance structure where identified.
6. Apply the duty of candour where harm has occurred The statutory duty of candour requires organisations to be open and honest with patients when things go wrong. The GPhC standards for pharmacy professionals also require candour regardless of the statutory threshold.\n\nWhen approaching a duty of candour conversation, prioritise understanding the patient's experience and concerns before explaining processes. Patients should have the opportunity to ask questions and be involved in discussions about next steps. Avoid conducting the conversation as a scripted checklist: the primary aim is to support the patient and address any ongoing risks to their care, not to complete a documentation exercise.\n\nIn practice: tell the patient what happened in plain language, apologise sincerely (an apology is not an admission of legal liability), explain what immediate actions have been taken, and offer support. Document the conversation contemporaneously. Experience consistently shows that open, prompt candour prevents formal complaints more often than it triggers them.

Quick decision guide: what to do with this event

What to Report Where: The Three-Category Framework

The key distinction is whether the error reached the patient and whether harm occurred or could have occurred.

Levels of Harm Used in LFPSE

When reporting a patient safety incident, you must assign a harm level. LFPSE harm categories cover physical and psychological harm. Harm categorisation depends on the actual outcome experienced by the patient, not the type of error alone: the same error can result in different harm levels depending on what happened.

LFPSE Account Types

Ensure appropriate administrative access exists within the organisation so that reporting and account management can be maintained at all times. Large multiple pharmacy groups may manage access centrally.

Recording and submission

• Complete an internal incident record promptly after any patient safety event or near miss.
• Key information to record internally:
  • Date, time, and location of the event
  • What happened: a clear factual description without staff names
  • Whether the error reached the patient
  • What immediate action was taken
  • Harm level (actual outcome, not assumed risk)
  • Whether a duty of candour conversation took place and what was said
  • Whether the event was submitted to LFPSE and the reference number
  • What learning action was agreed and by whom
• Information governance when submitting to LFPSE:
  • Do not enter unnecessary patient-identifiable information (name, NHS number, address) in free-text fields
  • Do not include staff names in event descriptions
  • Follow local information governance requirements and your organisation's LFPSE submission policy

Key takeaways

• LFPSE replaced NRLS in June 2024. Community pharmacies must have a route to report patient safety incidents to LFPSE, either directly at record.learn-from-patient-safety-events.nhs.uk or through an organisational process. Patient safety incidents that caused harm, could have caused harm, or identify a patient safety risk should be reported; routine near misses are recorded internally.
• Reporting to LFPSE does not replace urgent clinical action, Controlled Drug governance processes, safeguarding duties, or duty of candour obligations. CD incidents may require additional escalation through the Accountable Officer process regardless of any LFPSE submission.
• Every patient safety incident should be considered for learning, with the depth of review proportionate to the severity and recurrence risk. The GPhC expects evidence that incidents are reviewed, trends are monitored, learning is shared, and actions are followed up.

Download the checklist