Patient Safety Incident Response Framework (PSIRF)

What is the PSIRF?

The Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. It is being implemented across England to replace the Serious Incident Framework.

There are four key aims to the new framework:

Compassionate engagement and involvement of those affected by the patient safety incidents.
Application of a range of system-based approaches to learning from patient safety incidents.
Considered and proportionate responses to patient safety incidents.
Supportive oversight focused on strengthening learning and improvement across the trust, ICB and other services we work with.

The new PSIRF will be implemented at Homerton Healthcare from 1 February 2024.

You can read more about PSIRF on the NHS England website - NHS England » Patient Safety Incident Response Framework or watch this 4 minute video.

You can also watch a short video of our very own Breeda McManus and Linnie Pontin talking about implementing the PSIRF at Homerton. New Patient Safety Incident Framework (PSIRF) coming soon | Voices from across the Trust | Homerton Life

Our PSIRF policy is in the process of being approved and we'll link it here soon. We have a PSIRF plan that goes with the policy which details how learning and improvement will be maximised. It was developed based on our incident profile, ongoing improvement priorities, resource availability and the priorities identified by our stakeholders. You can read it here — Patient safety incident response plan

See below for more information about PSIRF and the differences you will see.

More questions?

You can contact the Quality and Patient Safety Team with any questions, concerns or feedback at huh-tr.patient.safety@nhs.net.

What will be different?

We will no longer be declaring Serious Incidents (SI) or using Root Cause Analysis (RCA) in response to incidents. The new framework will focus on understanding how incidents happen, instead of focusing on individuals.

Under the new PSIRF, learning responses will be used following incidents in line with our Policy and Plan.

This is a new way of doing things for all of us and sometimes we might not have the right answer straight away. There might be times when things need to be reviewed and a different direction taken when considering the appropriate learning response. The Quality and Patient Safety Team are here to support in these decisions and offer guidance.

The learning responses include:

Patient Safety Incident Investigation (PSII)

This will be completed by a Patient Safety Incident Investigator. The investigation will explore decisions and actions taken to understand what happened and help identify learning and improvement. The investigator will liaise with anyone involved in an incident, including the patient, family, carers, and staff. Everyone involved will have the opportunity to review the report before it is finalised.

After Action Review (AAR)

This is a structured review of the incident with those involved in the incident, and lead by a trained conductor. It focusses on 4 questions to aid understanding of what happened and identify any learning to take forwards. The questions are:

What did you expect to happen?
What actually happened?
Why was there a difference?
What can be learned?

Swarm Huddle

This is designed to happen as soon as possible after a patient safety incident occurs. It uses a Human Factors analysis approach to explore what happened, how it happened and decide what needs to be done to reduce the risk of it happening again.

Round Table Review

This is a type of MDT which seeks to identify learning from incidents through open discussion, identifying contributory factors and system gaps that impact on patient safety.

Thematic Review

This response can be used if there is a cluster of incidents that happen. It helps to understand any common links, themes or issues we can learn from and improve services to prevent the incidents occurring again.

It’s important to recognise there is a lot of amazing work being done already to address many risks and incidents we may see. The new framework also enables us to link these incidents together. It may mean making the decision that a learning response is not required for an incident because we are already learning and implementing changes to prevent it happening again. The resources are better used for the improvements rather than investigation. Again, the Quality and Patient Safety team are able to support with these decisions.

Systems-thinking and learning from patient safety incidents

We know patient safety incidents happen due to multiple interactions within the work system. As part of the learning responses, we will have a variety of tools we can use to aid us in identifying learning opportunities. The new PSIRF suggests the use of Safety Engineering Initiative for Patient Safety (SEIPS). The model supports us to have a systems-thinking approach to learning from incidents. It is a way of describing how different things in a work system can influence each other, which in turn influences the outcomes. It is based on a Human Factors approach to understanding care systems to inform better design and improvement.

The work system is analysed looking at 6 different elements: external environment, organisation, internal environment, tools and technology, tasks and person(s). People are specifically placed in the middle of the work system model to emphasise they cannot be separated from it.

Visual depiction of the SEIPS model

You can watch this short video giving an overview of the Safety Engineering Initiative for Patient Safety (SEIPS) model and making a cup of tea to help thinking with a systems approach.

What training is there?

A training package is being put together to ensure everyone has the knowledge and tools they need as we move across to PSIRF. This package includes:

The Patient Safety Syllabus (available on ESR)

For all staff - Patient Safety Syllabus Level 1: Essentials for Patient Safety
Band 7 clinical staff and above - Patient Safety Syllabus Level 2: Access to Practice – this is available online here A systems approach to investigating and learning from patient safety incidents - A systems approach to investigating and learning from patient safety incidents (canvaslms.com) but we will be running some in-person training too.
Board members and senior leadership - Patient Safety Syllabus: Essentials for patient safety boards and senior leadership

Training is being procured for those leading learning responses (including Patient Safety Incident Investigations and After Action Reviews), people engaging with patients, families, & colleagues, and people in oversight roles.