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What happens following a patient safety incident?
Where can I 昀椀nd more information about PSIRF?
How long will the investigation take?
At Patient Safety Learning, we produce and share a range of resources
about PSIRF which are primarily aimed at healthcare professionals.
They may also be helpful to patients and members of the public who
would like more in-depth information about processes and tools. A good
place to start is our PSIRF ‘Top picks’ articles:
Not all patient safety incidents will result in an investigation but,
when they do, the length of each investigation will vary. PSIRF aims
to reduce the time investigations take, to ensure patients and families
get answers more quickly and that actions are taken swifty to reduce
future harm.
• Top picks: PSIRF insights and opinions
The time an investigation takes depends on many factors, including:
• Top picks: PSIRF tools, templates and resources
• the complexity of the incident, including how many people are
involved
The NHS England website has extensive information about PSIRF,
including guidance on how healthcare organisations should work with
and include patients and families in investigations.
• the extent of the harm caused
• the approach taken to the investigation
• whether other similar incidents need to be investigated at the same
time
• the resources available to the patient safety and investigation team.
Who will talk to patients and families, and when can
they get involved?
Hospital trusts and healthcare organisations have dedicated patient
safety teams who lead on incident reviews and investigations and
ensure learning is applied to improve patient safety.
The Learn Together collaborative has produced a range of resources
to help patients understand PSIRF and how they might be involved in
patient safety investigations.
If you still have questions or would like to share your views on PSIRF,
start a conversation in our community area or comment on this blog
(you will need to join the hub for free first).
Share your experiences with us
We would love to hear about your views and experiences
of PSIRF:
Depending on the organisation’s structure, patients and family members
may be contacted by a range of different staff, including patient safety
team staff, dedicated incident response investigators, patient and
family liaison of昀椀cers, and patient safety managers.
• If you are a patient or healthcare professional who has been involved
in a PSIRF investigation, what was your experience like?
Patients and family members should be contacted and involved in the
process as early as possible and are likely to be asked for their account
of what happened and how the incident has affected them.
• https://www.pslhub.org/
Sharing concerns about the PSIRF process
If a patient or family member has concerns, they can raise these
with the department where they are receiving care or through an
organisation’s Patient Advice and Liaison Service (PALS), which offers
con昀椀dential advice and support, including information about how to
make a complaint. They can also contact the organisation’s patient
safety team about patient safety concerns, for example, if an incident
isn’t being investigated but they think it should be.
• What other questions do you have about how incidents are dealt
with in the NHS?
References
1. Report a patient safety incident. NHS England website, last accessed
23 November 2023.
2. Never events. NHS England website, last accessed 23 November
2023.
3. Patient Safety Incident Response Framework. NHS England website,
last accessed 20 September 2023.
4. Patient safety learning response toolkit. NHS England website, last
updated 17 August 2023.
Find out more 02921 680068 • e-mail admin@lawrand.com
Issue 399
December
2023
7