Understanding how we learn from patient safety incidents

The NHS is committed to learning from patient safety incidents to continuously improve care.

The Patient Safety Incident Response Framework (PSIRF) sets out how organisations should develop and maintain effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety.

PSIRF promotes a proportionate approach to responding to patient safety incidents by ensuring resources allocated to learning are balanced with those needed to deliver improvement. Its focus is on how incidents happen, including factors which contribute to them.

Independent patient safety investigations: purpose and process

The purpose of an independent patient safety investigation (IPSI) is to capture insight to inform improvement through investigation and exploration of the care, treatment and healthcare systems and processes for one or more patients at any level of the healthcare system.

They support the NHS to:

• be open and transparent about what happened and how it happened
• identify areas for improvement to reduce the possibility of a reoccurrence of similar events
• make recommendations for the improved delivery of health services in the future which can then be acted upon by relevant organisations with the power to make appropriate changes

IPSIs are only commissioned in limited circumstances, where it is considered appropriate to dedicate additional resources to the generation of insight due to the nature of the events in question.

An NHS England-commissioned IPSI does not apportion blame or liability. They do not hold people to account nor are they concerned with fitness to practice, criminal or other issues. However, the commissioning of an IPSI may occur alongside such processes.

Published independent investigation reports

Details of independent investigation reports that have been published by NHS England from April 2013 onwards can be found via the links below:

• Independent investigation reports for North East and Yorkshire
• Independent investigation reports for North West
• Independent investigation reports for the Midlands
• Independent investigation reports for the East of England
• Independent investigation reports for the South West
• Independent investigation reports for the South East
• Independent investigation reports for London

Find out more

Further guidance and information are available below:

• Patient Safety Incident Response Framework