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
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Abbreviation
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IN FULL |
|
AAR |
After action review |
|
CCG |
Clinical commissioning group |
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EA |
Early adopter (organisation) |
|
HSIB |
Healthcare Safety Investigation Branch |
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ICS |
Integrated Care System |
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LFPSE |
Learning from patient safety events |
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NHSE/I |
NHS England/Improvement |
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NLRS |
National learning and reporting system |
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PSC |
Patient safety collaborative |
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PSI |
Patient safety incident |
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PSII |
Patient safety incident investigation |
|
PSIRF |
Patient safety incident response framework |
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PSIRP |
Patient safety incident response plan |
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PSR |
Patient safety review |
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PSS |
Patient safety specialist |
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PST |
Patient safety team |
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RCA |
Roost cause analysis |
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SEIPS |
System engineering initiative for patient safety |
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SI |
Serious incident |
|
SIF |
Serious incident framework |
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SIP |
System improvement plan |
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StEIS |
Strategic Executive Information System |
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TOC |
Theory of change |
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TOR |
Terms of reference |
Key to the success of PSIRF is the application of system-based approaches to learning from patient safety incidents. In this podcast NHSE discuss the revised learning response toolkit, they are joined by guests Darren Thorne (Facere Melius), Jane Carthey (Human Factors and Patient Safety Consultant) and Laura Pickup (HSIB).
PSIRF preparation guide has been developed in conjunction with NHSE. It details the five phases of implementation ahead of the transition period to the new framework and embedding sustainable and meaningful change.
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.
Engaging and involving patients, families, and staff following a patient safety incident
Published alongside the Patient Safety Incident Response Framework(PSIRF), the ‘Guide to engaging and involving patients, families and staff following a patient safety incident’ sets out expectations for how those affected by an incident should be treated with compassion and involved in any investigation process. The guide has been produced by NHS England in partnership with the Healthcare Safety Investigation Branch and Learn Together. Joining us on this podcast to introduce the guide, discuss how it was developed, and future plans in the area of work, are Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implementation, both from the NHS England National Patient Safety Team; Lou Pye, Head of Family Engagement, at HSIB; and Jane O’Hara, from the Learn Together research team, who is a Professor of Healthcare Quality and Safety, University of Leeds and Deputy Director of the Yorkshire Quality and Safety Research Group.
Overview of PSIRF training requirements
This podcast focuses on the training NHS organisations should ensure staff undertake as part of their preparation for the implementation of the Patient Safety Incident Response Framework (PSIRF) by Autumn 2023. The podcast provides an introduction to the training requirements, the PSIRF training procurement framework, training offered by the Healthcare Safety Investigation Branch, and an overview of how this fits in with the wider national patient safety syllabus. Guests on the podcast are: Tracey Herlihey, Head of Patient Safety Incident Response Policy, in the national patient safety team, at NHS England; Nadine Mill, East of England NHS Collaborative Procurement Hub, Andrew Murphy-Pittock, head of investigation education, Healthcare Safety Investigation Branch; and Steve Cross, associate in patient safety, at the Academy of Medical Royal Colleges, and part of the Patient Safety Syllabus development team.
PSIRF Early Adopter interview – Patient Safety Investigators perspective
Megan is a Patient Safety Incident Investigator at the West Suffolk trust and here she discusses how PSIRF has influenced her approach to learning from patient safety incidents.
PSIRF Early Adopter interview – Mental Health Care provider
Norfolk and Suffolk NHS FT were involved in the PSIRF implementation as an early adopter, Saranna Burgess, director for patient safety at the trust discusses why the Trust decided to become part of the early adopters for PSIRF and the benefits she sees it bringing into patient safety.
PSIRF Early Adopter interview – Integrated Care Board perspective
Lisa Falconer, head of clinical quality and patient safety for Derby and Derbyshire CCG, discusses the PSIRF implementation from an ICB perspective and the improvements they have seen during the implementation period
