Patient Safety Incident Response Framework – guidance for those in governance

The Patient Safety Incident Response Framework (PSIRF) is the NHS’s new system based approach to patient safety to be implemented by all NHS organisations by Autumn 2023.  

Here we focus on clarifying the key differences between the former framework and PSIRF and provide guidance for those in governance.

Key differences

Serious Incident Framework 2015 (SIF)	Patient Safety Incident Response Framework 2022 (PSIRF)
Focus on serious incidents only.	Investigates any recorded patient safety incident that caused harm or could have caused harm.
Isolated investigations, linear approach.	System based methods, identifying themes.
National standard.	Tailored to local context.
Patient presented with outcome at end of investigation.	Patient involvement at the heart of the investigation, from the beginning.
Limited scope of investigations; Serious Incident report or Root Cause Analysis.	Flexible approach; Patient Safety Incident Response Plan (PSIRP), Patient Safety Incident Investigation (PSII), after action reviews, MDT review, ‘swarm’ meetings.
Focus on identifying root causes of harm.	Focus on improvement and learning.

Guidance for transitioning to PSIRF

Feedback from the early adopters of PSIRF includes that it requires organisations to change their mindset and approach the Framework as a collective. Among the recommendations made are targeting areas with the most cause for concern. Working with stakeholders to identify areas of interest in terms of risk and potential learning for improvement, has also been recommended.

Organisations are required to publish a PSIRP which must be agreed by the Integrated Care Board, other commissioning leads (where required) and the board of the relevant organisation, setting out its patient safety priorities and how it will respond to incidents. It is a ‘living document,’ that should be reviewed and updated every 12 to 18 months, with a more formal review every four years.

Organisations need to understand their capacity for responding to patient safety incidents such as the training and competencies of those involved in drafting the responses required.

Organisations must also map their services to ensure that their PSIRP reflects the variety of services offered.

There are numerous tools and documents online that have been developed by NHS England to assist organisations in transitioning to the new Framework.

Comment

PSIRF marks a great opportunity for organisations to have the freedom to make a change and meaningfully improve their patient safety. Organisations should be encouraged by the flexibility that the Framework allows and the movement away from identifying ‘root causes’ to a focus on learning for improvement.

From a claims and inquest perspective, PSIRF will result in a significant change in the evidence available for parties and the courts. Claimants and defendants in civil claims and families, interested persons and Coroners in inquests have typically relied upon the findings of Serious Incident reports and Root Cause Analysis investigations.

We recommend that organisations Legal Services teams take a proactive role in securing contemporaneous accounts following incidents, and locate relevant policies and guidance notes, so as to preserve evidence in the event of a claim arising.  

We are encouraged that PSIRF will change the focus of patient safety responses away from apportioning blame, to learning for the purposes of improvement which ultimately will lead to a safer NHS. This surely has to be best for the patient, as well as the healthcare professionals. For there to be meaningful and sustainable improvement however, there must be effective oversight, ownership and responsibility for improvement.

Related item: Patient Safety Incident Response Framework – implementation of the new approach and the anticipated benefits