The Operating Theatre Journal - Flipbook - Page 6
A simple guide to the Patient Safety
Incident Response Framework (PSIRF)
Summary
From Autumn 2023, NHS organisations in England are changing the way
they investigate patient safety incidents. NHS England has introduced
this new approach, which is called the Patient Safety Incident Response
Framework (PSIRF).
NHS England has produced detailed resources for patient safety leaders
and policy makers about the purpose of PSIRF and what organisations
are expected to do to deliver this part of the NHS Patient Safety
Strategy. However, discussions with frontline clinicians, patient safety
managers, educators and Patient Safety Partners have highlighted the
need for a simple guide that helps communicate PSIRF to a wide range
of stakeholders, including those who do not work in healthcare.
This guide provides some basic information about what PSIRF is
and why it’s been introduced. It also outlines what patients, carers
and family members can expect from an investigation if they are
involved in a patient safety incident.
Content
What is a ‘patient safety incident’?
A patient safety incident is when something goes wrong in a patient’s
care or treatment that causes them harm or has the potential to cause
harm.[1] This could be anything from being given the wrong dose of
medication to getting an infection after surgery.
Patient safety incidents vary in type and seriousness, and the NHS
has different ways of describing particular incidents. For example,
some very serious incidents are described as ‘Never events’ (things
that should never happen if procedures and guidance are correctly
followed).[2]
How are patient safety incidents reported and recorded?
Healthcare staff are required to report patient safety incidents. They
generally report through their organisation’s incident reporting systems
as part of a new service called Learning From Patient Safety Events
(LFPSE). When they input information about an incident, they categorise
it according to its type and record other relevant information. This
allows incidents to be assessed for their seriousness, and a decision
made about how to deal with the incident. If certain criteria are met,
a patient safety incident response or investigation will be triggered.
Recording incidents also allows organisations to spot trends of harm,
learn the reasons why these events happen and put measures in place
to stop similar incidents happening again in the same environment, or
more widely across the organisation. The learning can also be reviewed
and used more widely, locally by the Integrated Care System (ICS) and
nationally by NHS England.
Patients and family members can also record patient safety incidents
using the NHS England patient and public e-form, which is currently
being further developed. They are encouraged to always report
incidents to healthcare staff at the time they are involved in or witness
a patient safety incident. This is because just reporting it on the e-form
won’t on its own generate local learning or necessarily be reported to
each organisation.
How is PSIRF different from the previous investigation
process?
PSIRF replaces the previous approach to dealing with patient safety
incidents, the Serious Incident Framework (SIF), which was introduced
in 2015.
Under the SIF, hospitals were only required to investigate incidents that
reached the threshold for being de昀椀ned as ‘serious’. This sometimes
meant that ‘less serious’ incidents were not investigated or learned
from. For patients and families, the SIF process could be long and
drawn out, and patients sometimes reported feeling ‘shut out’ from
investigations.
PSIRF aims to provide a more 昀氀exible, transparent and compassionate
approach to learning responses and investigations, focused on
understanding the different factors that contributed to incidents and
ensuring organisations learn from them.
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NHS England states that the four key aims of PSIRF are[3]:
(*Our explanation of what each aim means)
1. Compassionate engagement and involvement of those affected
by patient safety incidents. Listening to patients, families and
staff involved in incidents with respect and care and involving them
meaningfully throughout the process.
2. Application of a range of system-based approaches to learning
from patient safety incidents. Using tools to help understand all
the different factors at play that have come together to contribute
to the incident.
3. Considered and proportionate responses to patient safety
incidents. Making sure the organisation chooses actions that are
appropriate to help understand what happened, learn from it and to
reduce the risk of future harm.
4. Supportive oversight focused on strengthening response system
functioning and improvement. Making sure patient safety managers
and leaders help all staff apply the lessons learned from incident
reviews and investigations so that the team and wider organisation
work in a safer way. Making sure this insight is shared for wider
learning in local and national systems.
Which incidents will be investigated under PSIRF?
Each healthcare organisation needs to publish its own Patient Safety
Incident Response Plan (PSIRP). This will outline which patient safety
incidents should be reviewed and investigated and which approach
should be applied in different scenarios.
This document should be available to access publicly on each
organisation’s website. If you have issues 昀椀nding a PSIRP, you can look
it up in our PSIRP 昀椀nder, or contact your healthcare organisation to
request a copy. Our PSIRP 昀椀nder is a work in progress and we are aiming
to collect PSIRPs from as many organisations as possible. If you are
aware of a PSIRP that isn’t listed in our 昀椀nder, please contact us so that
we can add it.
What practical changes will PSIRF make to how incidents are responded
to and how investigations will work?
PSIRF introduces and promotes a wider range of investigation
approaches than were used under the SIF. Different tools, approaches
and formats may be used in different circumstances, and this will be
determined by an organisation’s PSIRP.
Some examples listed by NHS England [4] are:
• Patient Safety Incident Investigation (PSII)—an investigation that
takes place when an incident or near-miss has signi昀椀cant patient
safety risks and the potential for new learning.
• After Action Reviews (AARs)—a technique used to capture learning
from an activity or event that has that has gone well or has resulted
in patient harm.
• Thematic reviews—which aim to identify patterns in data to help
answer questions, show links or identify issues.
• Swarm huddle—this involves staff ‘swarming’ to the site of an
incident as soon as possible to analyse what happened, understand
how it happened and decide what needs to be done to reduce the
risk of it happening again.
Who does PSIRF apply to?
PSIRF applies to all NHS acute, ambulance, mental health, community,
maternity and specialised services. It also applies to independent
(private) healthcare providers who deliver services under the NHS
standard contract. Primary care organisations and GP services aren’t
required to adopt PSIRF at this stage, but they may choose to use some
PSIRF approaches.
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