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Wednesday, 07 December 2022

Patient Safety Incident Response Framework

Following NHS England’s publication of the new Patient Safety Incident Response Framework (PSIRF) which introduces a fundamental shift in the NHS’s approach to responding to patient safety incidents, our Trust has set up an implementation group to take this forward.

The framework is a major step towards establishing a safety management system that embeds the key principles of a patient safety culture, introducing a focus on understanding how incidents happen, rather than apportioning blame; allowing for more effective learning, and ultimately safer care for patients.

Our Trust takes learning from incidents extremely seriously, and welcomes this change. Our implementation group, chaired by our Head of Nursing and Quality Sharon Spain, meets monthly to review and agree the actions our Trust is taking to implement this new framework.

A key aim of PSIRF is to allow organisations to focus learning response resources on areas where improvement will have the greatest impact. This will be based on our local incident profile and existing improvement work, our organisation will identify areas that will benefit most from patient safety incident response, to create our patient safety incident response policy and plan.

PSIRF removes many constrictions around the approach to investigations, particularly around the criteria and response surrounding incidents that are deemed to be ‘serious incidents’ or not, and provides a more flexible framework to undertake the right type of review or investigation which is proportionate, but also focus more on themes and better triangulation. This enables resources to be focused more effectively on the identified areas with the greatest potential for patient safety improvement; and enable responses to look at incidents that many not have met the serious incident criteria but where important learning can still be gained.

Published alongside the framework, the ‘Guide to engaging and involving patients, families and staff following a patient safety incident’, also sets out expectations for how those affected by an incident, for example, patients, families and staff, should be treated with compassion and involved in any investigation process. This is an area the Trust is doing well and aims to improve further.

NHS organisations such as ours are now beginning a 12-month period of preparation before transitioning to PSIRF from the existing Serious Incident Framework. A range of resources to support this process are available on the NHS England website. The implementation team are linking in with the national patient safety team who are providing further support via the patient safety collaboratives, and a range of webinars and podcasts over the next 12 months.

We will keep you updated with how we plan to implement this framework at our Trust so we continue to improve the high standards of care we provide.


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