Insights
The Patient Safety Incident Response Framework (PSIRF) outlines how NHS organisations should respond to patient safety incidents and ensure learning and improvement is recognised and embedded. PSIRF was introduced in 2022, replacing the previous Serious Incident Framework. It represents a significant shift in focus to involving those affected and making sure responses are considered, compassionate, proportionate and supportive.
PSIRF represents a major step towards improving safety management across England and supports the NHS to embed the key principles of a patient safety culture. It seeks to understand how incidents happen, rather than apportioning blame to individuals, which leads to more effective learning and improvement and ultimately safer care for patients.
The principles of a patient safety culture
The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:
– Compassionate engagement and involvement of those affected by patient safety incidents
– Application of a range of system-based approached to learning from patient safety incidents
– Considered and proportionate responses to patient safety incidents
– Supportive oversight focused on strengthening response system functioning and improvement
PSIRF can also help to mitigate where health inequalities contribute to patient safety incidents. PSIRF may account for and anticipate the needs and vulnerabilities of marginalised groups in a broader sense than was possible using the previous framework, and by shifting focus from reactive responses to proactive learning and continuous improvement, it aims to create a safer environment for both patients and healthcare workers.
Intervention
The implementation of PSIRF in local health and care systems has been supported by the East of England Patient Safety Collaborative. Health Innovation East carried out an evaluation of the progress so far, and to understand future support requirements.
Evaluating PSIRF
Initially, learning events were facilitated for the patient safety specialist networks in the region whilst waiting for the launch of the final PSIRF guidance. These sessions were to provide a space for colleagues from the region’s health and care systems to learn from the experiences of Suffolk and North East Essex (SNEE) who were early adopters of PSIRF.
The regional approach was developed to connect colleagues through collaborative webinars and a series of in-person workshops to help develop a shared understanding for the implementation of the PSIRF guidance.
The team also co-ordinated monthly regional meetings for leaders from Integrated Care Boards (ICBs) in the region to celebrate successes and share advice on overcoming the challenges of system transformation.
Sarah Hamilton, Senior Improvement Lead, explained: ‘Connecting expertise, accelerating understanding, and delivering frameworks around which they can operate has been key to the successful implementation of PSIRF. We also developed and delivered a regional community of practice, which held its first session in May 2024. These are now being held in partnership with organisations in the region every six months.’
Impact
The evaluation found that the Patient Safety Collaborative’s role has been instrumental in guiding ICB and regional leads, helping to facilitate change, and to create and host meaningful and supportive networking opportunities.
The intervention was forward-thinking, fostered collective understanding, and created safe spaces in which to share successes and overcome challenges.
The evaluation result received positive feedback from ICB and regional NHS leads, alongside patient safety specialists. They appreciated the Patient Safety Collaborative’s role in bringing the key stakeholders together, and appreciate its continued support.
86% of survey respondents strongly agreed or agreed that the events and activities they attended had supported their ability to implement and embed PSIRF in their organisation.
What colleagues experienced
‘We’re continuing as a community of practice, but I don’t think that would have been anywhere near where it is now without [the Patient Safety Collaborative] driving that at the beginning which is great; [they] put us in such a comfortable position moving forward.’
‘The PSC has been very good at bringing all of the system partners together, making sure we’re all receiving the same message.’
‘You know when you’re approaching someone in the PSC, you’re going to get a sensible answer.’
‘In the short time I’ve been in the role, I’ve seen huge progression with [moving from a culture of blame to a culture of learning], really, really positive progress.’
Successfully implementing and embedding PSIRF within the East of England may lead to a number of additional benefits, such as:
- Improved patient outcomes and fewer repeated incidents: reducing the patient impact and cost-burden of adverse events or complications.
- Lower training costs: from a more structured approach to learning from patient safety events.
- Improved resource allocation and management: a system optimised for learning and improvement, rather than investigating single incidents and dealing with costly emergency responses.
- Staff efficiency: from streamlined response processes.
The journey continues
The journey to embed PSIRF continues. The East of England Patient Safety Collaborative will support in line with our commission from NHS England, and take the lessons learned from this process to inform future safety improvement changes across the region.
Find out more
Find out more about system safety and PSIRF.