Patient Safety Incident Response Framework

To support the NHS to further improve patient safety, we are preparing for the introduction of a new Patient Safety Incident Response Framework (PSIRF), outlining how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.

Latest update

We are aiming to publish the Patient Safety Incident Response Framework in early August 2022, at which point this page will be updated with the framework document, associated guidance, templates and tools, as well as a range of information and resources to support providers to prepare to implement PSIRF.

Webinar – Implementing the new Patient Safety Incident Response Framework. 5 September 2022, 2pm

To support providers to start the process of preparing for PSIRF we will be hosting a webinar on 5 September. Further details can be found on the event page, where you can also book a place.

The PSIRF is a key part of the NHS Patient Safety Strategy published in July 2019. It supports the strategy’s aim to help the NHS to improve its understanding of safety by drawing insight from patient safety incidents.

Working with early adopters

To test an introductory version of the PSIRF, we worked with a small number of early adopters who piloted the framework in their organisations between March 2020 and June 2022. A list of the early adopters can be found at the bottom of this page.

This testing phase has informed the creation of the final version of the PSIRF which we aim to publish early August 2022.

At that point, other providers of NHS funded care in England who are not early adopters will also begin preparing to adopt the new framework. We expect secondary care providers to complete the transition from the current Serious Incident Framework to PSIRF by Autumn 2023.

List of early adopters

We worked with groups of organisations in each NHS region as early adopters, together with one organisation that works nationally.

Listed by region, the early adopter organisations were:

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

Responding to patient safety incidents patient story videos

We have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient

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.

Developing the 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.

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