Patient Safety Incident Response Framework

The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

Aidan Fowler, National Director of Patient Safety, NHS England – “The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen – including the factors which contribute to them.“

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Rt Hon Jeremy Hunt, MP – “The new Patient Safety Incident Response Framework is very welcome. It is great to see the involvement of those affected by patient safety incidents at its heart and the emphasis on learning and improvement are vital if we are to reduce avoidable harm across the NHS.“

A new approach to responding to patient safety incidents

The PSIRF will replace the current Serious Incident Framework (2015).

The framework  represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. It is a key part of the NHS patient safety strategy.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

  1. Compassionate engagement and involvement of those affected by patient safety incidents
  2. Application of a range of system-based approached to learning from patient safety incidents
  3. Considered and proportionate responses to patient safety incidents
  4. Supportive oversight focused on strengthening response system functioning and improvement

Who does PSIRF apply to?

The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Primary care providers may also wish to adopt PSIRF, but it is not a requirement at this stage. Further exploration is required to ensure successful implementation of the PSIRF approaches within primary care.

Dr Sean O’Kelly, Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services, Care Quality Commission – “We welcome the publication of NHS England’s new Patient Safety Incident Response Framework (PSIRF) and the focus it places on effective learning and compassionate, meaningful engagement with those affected when incidents occur. Through our monitoring and inspection we have seen how the existence of a strong organisational safety culture, where the views of staff and patients are listened to and acted on, and learning is prioritised is essential to good practice in responding when things go wrong.”

Saffron Cordery, Interim Chief Executive, NHS Providers – “We welcome this framework as a key tool to ensure that investigation processes and responses by trusts lead to effective learning and improvement, contributing to better patient safety and outcomes – the top priority of trust leaders.”

Early adopters share their experiences

In the videos below early adopters describe their experience of implementing PSIRF

Lucy Winstanley, Head of Patient Safety and Quality, West Suffolk NHS Foundation Trust

Megan Pontin, Patient Safety Incident Investigator, West Suffolk NHS Foundation Trust

Saranna Burges, Director for Patent Safety and Quality, Norfolk and Suffolk NHS Foundation Trust

Lisa Falconer, Head of Clinical Quality and Patient Safety, NHS Derby and Derbyshire CCG

Preparing for PSIRF

Implementation of PSIRF will not be achieved by a change in policy alone, and it cannot be implemented in days or weeks as it requires work to design a new set of systems and processes. To help organisations prepare to transition to PSIRF we have developed a preparation guide to support those leading PSIRF implementation across the NHS.

Organisations are expected to transition to PSIRF within 12 months of its publication, and transition should be completed by Autumn 2023. The preparation guide breaks PSIRF preparation into six phases to ease transition and provide detail around discrete activities that will set strong foundations for implementing the framework.

Dr Rosie Benneyworth, Interim Chief Investigator at the Healthcare Safety Investigation Branch (HSIB) – “We welcome the publication of the Patient Safety Incident Response Framework (PSIRF), a significant development in the patient safety landscape in England. PSIRF reflects the key principle that guides our national patient safety investigations – a focus on understanding how incidents happen rather than attributing blame or liability – and applies this to local investigations. As well as co-authoring the supporting guidance around involving patients, families and staff, HSIB has developed a range of training courses to help NHS trusts put PSIRF into practice.”

Supporting documents

The PSIRF is supported by further detail provided in four guidance documents:

  • Engaging and involving patients, families and staff following a patient safety incident
  • Guide to responding proportionately to patient safety incidents
  • Oversight roles and responsibilities specification
  • Patient safety incident response standards

We have also produced templates to guide organisations through the development of their patient safety incident response policy and patient safety incident response plan

Engaging and involving patients, families and staff following a patient safety incident

Compassionate engagement and involvement of those affected by patient safety incidents is central to PSIRF.

Please visit our Engaging and involving patients, families and staff following a patient safety incident webpage for further information.

Learning response toolkit

The PSIRF promotes a range of system-based approaches for learning from patient safety incidents. Organisations are encouraged to use the national tools and guides available in our learning response toolkit.

The national tools have been developed in collaboration with human factors experts and the Healthcare Safety Investigation Branch, who lead the way in modern healthcare safety investigation methodology. They have been tested with representative end users whose feedback has been instrumental in informing the design.

The Patient Safety Incident Investigation report template should be adopted unamended. We will continue to review and evaluate the design of the template.

If you would like to provide feedback, please contact patientsafety.enquiries@nhs.net

Join our PSIRF FutureNHS workspace

Further resources (including webinars, podcasts and additional tools) to support providers to prepare, transition and work under PSIRF will be made available throughout 22/23 via our PSIRF FutureNHS workspace. This workspace is part of the NHS Patient Safety workspace

We will also use this workspace to communicate with staff and local stakeholders via the message board. This workspace is available for anyone to join (you don’t need an NHS email). If you’re not a member and would like to join please email NHSps-manager@future.nhs.uk.

Developing PSIRF

Reports by the Public Administration Select Committee in March 2015; the Government’s response in July 2015; the Parliamentary and Health Service Ombudsman’s report in December 2015; the CQC’s report in June 2016, and the CQC’s report in Dec 2016 all identified shortcomings in the way patient safety incidents are investigated and learned from.

In response to these reports, in 2018 we conducted a widespread engagement exercise around the future of NHS patient safety investigation to gather thoughts and feedback to support us to develop the PSIRF to replace the existing Serious Incident Framework.

The PSIRF was developed based on the feedback received through our The future of NHS patient safety investigation engagement activity.

Published in March 2020 the Introductory PSIRF was tested by 24 early adopters (including 17 provider organisations alongside their commissioners and regional leads) for two years. The early adopter programme was independently evaluated and alongside feedback from our early adopters has informed the development of the PSIRF (2022).

The evaluation report is available on our FutureNHS workspace.

List of early adopters

Listed by region, we would like to thank the following early adopter organisations that have been instrumental in the development of the final version of the PSIRF:

East

  • Norfolk and Suffolk NHS Foundation Trust
  • East Suffolk and North Essex NHS Foundation Trust
  • Essex Partnership University Foundation Trust
  • West Suffolk NHS Foundation Trust
  • NHS Suffolk and North East Essex CCG/ICS

London

  • London Ambulance Service NHS Trust
  • North West London Collaboration of CCGs

Midlands

  • Chesterfield Royal Hospital NHS Foundation Trust
  • Derbyshire Community Health Services NHS Foundation Trust
  • Derbyshire Healthcare NHS Foundation Trust
  • Derbyshire Health United
  • University Hospital Derby and Burton NHS Foundation Trust
  • NHS Derby and Derbyshire CCG/STP

National

  • Care UK (Independent provider of healthcare in prisons)
  • North East and Yorkshire
  • Leeds Teaching Hospitals NHS Trust
  • NHS Leeds CCG

North West

  • East Lancashire Hospitals NHS Trust
  • NHS East Lancashire CCG

South East

  • Isle of Wight NHS Trust
  • NHS Isle of Wight CCG

South West

  • Cornwall Partnership NHS Foundation Trust
  • North Bristol NHS Trust
  • Royal Cornwall Hospitals NHS Trust
  • NHS Kernow CCG

Get in touch

If you would like to get in touch, please contact Patientsafety.enquiries@nhs.net.

Alternatively, you can use the PSIRF discussion board on our FutureNHS platform.