The PSIRF is part of the NHS Patient Safety Strategy and outlines how providers should respond to patient safety incidents. It will be implemented in all NHS organisations starting in Spring 2022, and will replace the Serious Incident Framework.
Instead of having a defined list of serious incidents, there will be a systems-based learning approach to patient safety with a smaller list of incident categories that will need to be reported externally (via StEIS). This will include Never Events, Patient Deaths, Mental Health Homicides and Maternal and Neonatal deaths which meet “Each Baby Counts” criteria.
The PSIRF takes a risk-based approach which is more proactive and allows for prioritisation of incident reviews within the organisation.
The purpose of these changes is to make sure reviews are designed for safety and learning rather than performance management. Timescales for reviews will be agreed with patients and their families and will be completed on a new template with a new methodology (no longer root cause analysis).
Further information can be found in the Introductory version of the Patient Safety Incident Response Framework
Tracey Herlihey and Lauren Mosley, Patient Safety Implementation at NHSE England and Improvement have produced a podcast explaining the Patient Safety Incident Response Framework (PSIRF). You can listen to the podcast here.
The framework is a key component of National Patient Safety Strategy and will start to replace the current Serious Incident Framework (SIF) from Spring 2022.
The SIF provided structure and guidance on how to identify, report and investigate an incident resulting in severe harm or death. However, PSIRF is best considered as a learning and improvement framework with the emphasis placed on the system and culture that support continuous improvement in patient safety through how we respond to patient safety incidents.
One of the underpinning principles of PSIRF is to do fewer “investigations” but to do them better. Better means taking the time to conduct systems based investigations by staff that have been trained to do them. The new strategy also challenges us to think differently about learning and what it means for a healthcare organisation.
If you have any further queries or would like more information, please contact: PSIRFenquiries
The Patient Safety Specialist role is in place to encourage a culture of patient safety across the Trust. The Patient Safety Specialist will:
- Escalate risks or issues to the executive team
- Work in networks with Patient Safety Specialists in other organisations to share good practice
- Lead and support patient safety improvement
- Ensure that systems thinking, human factors understanding and just culture principles are embedded in all patient safety processes
The Patient Safety Specialist for Mersey Care is Panchu Xavier.
Patient Safety Partners (PSPs) are patients, family members or other members of the public who work with the Trust to improve patient safety. The purpose of introducing patient safety partners is to promote transparency and openness, help the Trust to understand what feels unsafe to patients, and to help the trust to provide information that is accessible to patients.
The NHS Patient Safety Strategy requires all Patient Safety and Governance committees to include 2 trained PSPs by July 2023.
PSIRP – GLOSSARY OF TERMS
|
Abbreviation
|
IN FULL |
|
AAR |
After action review |
|
CCG |
Clinical commissioning group |
|
EA |
Early adopter (organisation) |
|
HSIB |
Healthcare Safety Investigation Branch |
|
ICS |
Integrated Care System |
|
LFPSE |
Learning from patient safety events |
|
NHSE/I |
NHS England/Improvement |
|
NLRS |
National learning and reporting system |
|
PSC |
Patient safety collaborative |
|
PSI |
Patient safety incident |
|
PSII |
Patient safety incident investigation |
|
PSIRF |
Patient safety incident response framework |
|
PSIRP |
Patient safety incident response plan |
|
PSR |
Patient safety review |
|
PSS |
Patient safety specialist |
|
PST |
Patient safety team |
|
RCA |
Roost cause analysis |
|
SEIPS |
System engineering initiative for patient safety |
|
SI |
Serious incident |
|
SIF |
Serious incident framework |
|
SIP |
System improvement plan |
|
StEIS |
Strategic Executive Information System |
|
TOC |
Theory of change |
|
TOR |
Terms of reference |
Responding to patient safety incidents – Kathryn’s story
Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed
Responding to patient safety incidents – Kirsty’s story
Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip.
Responding to patient safety incidents – Valerie’s story
Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication.
