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.
While work on the PSIRF has been able to resume, organisations continue to respond to ongoing challenges associated with COVID-19, and those associated with the restoration of services. Timeframes are therefore subject to change.
We expect preparation for implementation to be a gradual process that will commence in Spring 2022; further details about the approach will be shared in due course. We do not expect organisations to be ready to implement PSIRF from April 2022 and organisations should not feel pressure to start to create a PSIRF Plan at this stage.
Please note the documents on this page and the Patient safety investigation resources page will be revised following the completion of our work with early adopters, but are still available for information only.
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 the PSIRF, we are first working with a small number of early adopters who are using an introductory version of the framework in their organisations. A list of the early adopters can be found at the bottom of this page.
This testing phase will be used to inform the creation of a final version of the PSIRF which we anticipate will be published in Spring 2022.
At that point, other providers of NHS funded care in England who are not early adopters will also begin adopting the new framework. The timeframe for this transition will be informed by the pilot with early adopter organisations.
Introductory version of the PSIRF
Until instructed to change to the PSIRF (likely from Spring 2022), non-early adopter organisations must continue to use the existing Serious Incident Framework.
While we are not asking organisations other than the early adopters to transition to the PSIRF yet, we want to help providers outside of the early adopter areas to plan for this change. We have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2022.
As mentioned above, the documents below will be revised following the completion of our work with early adopters, but are still available for information only.
- Introductory version of the Patient Safety Incident Response Framework – The introductory version of the Patient Safety Incident Response Framework that is being tested with early adopters.
- Patient Safety Incident Response Plan (PSIRP) template – A template to guide local early adopter organisations in prioritising investigation quality over quantity
- Patient Safety Incident Investigation Standards – Standards for commissioners, boards and investigators in the commissioning, oversight, conduct and use of patient safety incident investigations
PSIRF implementation timescales
Our current timescale for the roll out and implementation of PSIRF across the NHS in England is as follows (dates are subject to change):
- March 2020 – work begins with early adopters and PSIRF published as introductory guidance. Other providers continue to use the Serious Incident Framework
- Spring 2022 – final PSIRF will be published reflecting our work with early adopters. All providers begin to transition to the PSIRF
Patient safety investigation resources
We have also updated a range of resources to support NHS organisations to conduct patient safety incident investigations (PSIIs).
List of early adopters
We are working 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 are:
- 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 Ambulance Service NHS Trust
- North West London Collaboration of CCGs
- 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
- Care UK (Independent provider of healthcare in prisons)
North East and Yorkshire
- Leeds Teaching Hospitals NHS Trust
- NHS Leeds CCG
- East Lancashire Hospitals NHS Trust
- NHS East Lancashire CCG
- Isle of Wight NHS Trust
- NHS Isle of Wight CCG
- 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.
- The future of NHS patient safety investigation: engagement feedback – This archived document summarises the feedback received through our The future of NHS patient safety engagement activity.