PSIRF and the Mersey Care response to patient safety incidents
The Patient Safety Incident Response Framework (PSIRF) is part of the NHS Patient Safety Strategy and outlines how providers should respond to patient safety incidents. It has been implemented across all NHS commissioned care (not mandatory for Primary Care). This replaced the previous Serious Incident Framework in Mersey Care in July 2023.
The Trust worked in collaboration with colleagues (internal and external) to develop our Patient Safety Incident Response policy that sets out our principles for using PSIRF drawing on our own Trust values. Our first Patient Safety Incident Response plan outlines how we operate PSIRF and will be reviewed and updated in 2025. The plan identifies both the currrent national and Mersey Care's own local priorities to review patient safety incidents.
You can download a highlight version of Mersey Care's PSIRF policy and plan. This has been shared with key internal and external stakeholders. This highlight version will be amended to include any 2025 changes.
The Patient Safety team and Divisions continue to work together to ensure that that procedures and documentation are in place to operate PSIRF effectively. The PSIRF workbook, developed to be used by colleagues as an operating guide for PSIRF, is currently in review to ensure that the 2025 changes to our plan and policy are incorporated.
Communications
Any updates to PSIRF will be issued via the Trust communication bulletin. We will also have regular direct communication on PSIRF developments with key Trust and Divisional staff.
The first edition of the Trust's PSIRF plan expires in 2025 and we will be seeking wide participation in the development of our plan for the next edition throughout 2025. Look out for information on how you can become involved in this development in the Communications bulletin.
For a basic introduction into PSIRF click on the presentation at the top of this intranet page.
For information on the background to PSIRF click on the links below.
Main differences between Serious Incident framework and PSIRF
NHS England have developed a practical guide to improving patient safety culture
improving-patient-safety-culture-a-practical-guide-v2.pdf (england.nhs.uk)
Patient Stories
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.
Podcasts and videos
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 was produced by NHS England in partnership with the Healthcare Safety Investigation Branch and Learn Together.
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). 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.
PSIRF Early Adopter interview – Patient Safety Investigators perspective
This podcast includes discussion with a Patient Safety reviewer from West Suffolk Trust who were PSIRF early adopters. The reviewer discusses how PSIRF has influenced her approach to learning from patient safety incidents.
PSIRF Early Adopter interview – Mental Health Care provider
In this podcast the Director of Patient Safety at an early adopter Trust discusses the benefits of PSIRF on Patient Safety.
PSIRF Early Adopter interview – Integrated Care Board (ICB) perspective
In this podcast a head of Clinical Quality in Patient Safety discusses PSIRF implementation and the improvements they have seen during the implementation period
(ICBs commission the care we provide)
We report our patient safety incidents to the central national data repository, known as Learning from Patient Safety Events (LFPSE).
Find out more in the user guide.
The Trust will move to using version 6 of the LFPSE national form from Simmer 2025. The Patient Safety team will support you through the change with regular messages in the Communications bulletins, extranet and YourSpace to make sure you know how this impacts you. All patient safety incidents entered onto Radar will continue to be reported directly to NHS England.
NHS England have advised on harm levels for both physical and psychological harm and these (definitions) can also be found in our guide and in the aide memoire at the top of this Patient Safety site.
We have collated a document of frequently asked questions from the open table events. This document will be updated when required.
Separating fact from fiction. NHSE have developed a document to dispel common misconceptions surrounding PSIRF
Please see responses to the questions raised at the Clinical Senate on Tuesday 18th April 2023.
A key principle of PSIRF is to take a considered and proportional response to patient safety incidents. Mersey Care have adopted a number of system based approaches to learn and improve as a result of a patient safety incident.
Listed below are the approved documents which form the Trust response under PSIRF.
Initial response
High Secure Managers Action Card
Rapid Review Document - Initial Review only
Patient Safety Reviews
View the attached document for the patient safety review toolkit briefing.
Thematic Review Report template
Patient Safety Learning Response Review
Patient Safety Partners (PSPs) are patients, family members or other members of the public who work with the Trust to improve patient safety. The NHS Patient Safety Strategy required that Trusts have a minimum of 2 PSP's. The main purpose of introducing patient safety partners is to promote transparency and openness, and to be a voice for the patients and community who use our services. They will help the Trust make sure that patient safety is at the forefront of all that we do.
We have 2 PSPs who support the Patient Safety team and Divisions in to make sure that patient centredness is part of what we do.
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 Specialists for Mersey Care are
Dr Panchu Xavier - Director of Patient Safety
Nicky Ore - Deputy Director of Patient Safety
Claire Brockbank - Head of Integrated Governance - Safety
Kim Bennett - Patient Safety Specialist
One of the principles of PSIRF is compassionate engagement of those affected by a patient safety incident.
The Patient Safety team have adapted a national booklet developed by Learn Together in order to share with patients, families and carers who have been affected by a patient safety incident and when a PSLR is being undertaken.
A similar booklet will be available for staff who have been affected by a patient safety incident and when a PSLR is being undertaken.
These leaflets do not need to be shared for any other type of patient safety review but please feel free to read the content.
The NHS Patient Safety Strategy included the introduction of national patient safety education for all NHS employees. You will notice that patient safety training is now a mandatory requirement on your ESR profile.
Some individuals in more senior roles, who may be involved in decision making or oversight of patient safety incidents, should also attend PSIRF training so that Mersey Care can comply with the national patient safety response standards.
- Module 1 is split into 2 parts (1 and 2) and is an introduction to the system-based approach to patient safety incidents
- Module 2 focuses on engaging with those involved in patient safety incidents
- Module 3 is for those senior staff involved in the oversight of patient safety incidents
Please note that Module 1 should be completed prior to moving on to the other sessions. Parts one and two of Module 1 need to be undertaken in that order. and the courses should be viewed as a 'package' of learning. If you attended the AQUA engagement training, you do not need to attend module 2.
Simply send your requested dates to PSIRFenquiries@merseycare.nhs.uk or contact Kim Bennett, Patient Safety Specialist to discuss your individual training needs before booking
Upcoming training dates
| Modules | Dates |
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Systems-based approach to learning from patient safety incidents |
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Systems-based approach to learning from patient safety incidents |
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Engaging and Involving those affected by a patient safety incident |
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Oversight of patient safety incidents |
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Shortened sessions based on the modules above are planned for teamleaders from October 2024.
If you wish to take your learning further, HSSIB (Health Services Safety Investigation Body) offer free courses in skills that will help you for patient safety reviews. They are free for NHS employees.
PSIRF - what it means for you!
PSIRF Initial Rapid Review
This video includes details of our response to patient safety incidents under PSIRF and advice on how to complete the initial rapid review.
Introduction to system-based approach to review of patient safety incidents
