Patient Safety Incident Response Framework

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Patient Safety Incident Response Framework

What is Patient Safety Incident Response Framework (PSIRF)?

PSIRF sets out a new direction for how the NHS responds to patient safety incidents, focusing on learning and improving patient safety.

Patient safety incidents are unintended or unexpected events (including omissions) in healthcare that could have or did harm one or more patient.

It supports the development and maintenance of an effective patient safety incident response system, with four key aims:

  • Compassionate engagement and involvement of those affected by patient safety incidents
  • Application of a range of system-based approached to learning from patient safety incidents
  • Considered and proportionate responses to patient safety incidents
  • Supportive oversight focused on strengthening response system functioning and improvement

Previously, only incidents that have caused serious harm and meet set criteria were investigated.

Under PSIRF:

  • We will have greater freedom to investigate incidents that provide the most potential for new learning and improvement
  • We will learn from incidents using a range of different learning tools
  • Learning from incidents will be on a flexible timeframe, depending on the nature of the investigation and will be agreed with the patient and/or their family
  • Investigations will be led by those trained in the correct methodology, who meet set competency requirements. Investigators will have the authority to act autonomously and will have dedicated time and resources

The regulatory requirement for Duty of Candour will not change. We still have a legal responsibility to be open and transparent with patients, their families or loved ones when things go wrong.

  • Greater focus on understanding the impact of systems and human factors in patient safety incidents
  • Better understanding of the ‘what’ not the ‘who’ in investigations to support a just and open learning culture
  • Greater support and involvement for those involved in patient safety incidents including staff as well as patients and their families
  • Not all serious incidents will lead to a patient safety incident investigation – there are other tools to use such as a Huddle, After Action Review, Thematic Review, Audit or an MDT Review

All this should lead to greater improvements in patient safety.

There’s loads of information about PSIRF on the NHS England website.

Organisations are required to apply PSIRF in the development and maintenance of a patient safety incident response policy and plan.

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