The safety loop
Every incident or near miss is a chance to check the hazard log. Listed already? A control may have failed. Not listed? You’ve found a new hazard.
- Something happensAn incident or near miss
- Record itIn the incident log
- CSO reviewsIs it a new hazard, or a control failing?
- Update the hazard logNew or stronger controls (or mitigations)
- Tell peopleThe patient, staff, the supplier, and the national Learning from Patient Safety Events (LFPSE) service if needed
Keep one incident log for all your digital tools, alongside your significant event process.
Who to tell
- AlwaysYour CSO, and record it locally
- The tool contributedThe supplier, who should have an escalation route for safety issues
- A patient was or could have been harmedThe patient (duty of candour), and the national LFPSE service1
- It’s a medical deviceThe MHRA Yellow Card scheme
- Data went somewhere it shouldn’tYour Caldicott Guardian and DPO straight away: it’s a data breach
Keeping watch
Five minutes on digital tools at the monthly clinical governance meeting, where incidents and what was learned are shared, and a monthly check of ten random examples. That audit makes a good QI project for a GP registrar or FY2.
Example check: AI scribe notes
- Was the patient asked, and the answer recorded? Every note
- Does the note include anything that wasn’t said? Nothing
- Are the plan and safety-netting recorded? Yes
When to look again
- A significant update or new feature
- A new way of using it
- An incident that shows a new hazard
- New national guidance
- A year since the last review
Switching a tool off has risks too: finish open work, get the supplier’s data handling in writing, and update the register.
References
Sources on this page last checked 3 November 2026.