Significant variation and gaps found in Patient Safety Incident Response Plans, says charity

An analysis by the charity Patient Safety Learning has found significant differences in approach and critical information gaps in healthcare providers Patient Safety Incident Response Plans.

In a new report published, Patient Safety Learning has analysed a sample of NHS Trusts Patient Safety Incident Response Plans, looking at what these tell us about the implementation of PSIRF to date.

Based on its findings, the report identifies five recommendations intended to improve the approach to creating, implementing and reviewing Patient Safety Incident Response Plans. Central to this is a recommendation to develop a national standardised framework for evaluating these plans.

Commenting on the report, Patient Safety Learning Chief Executive Helen Hughes said:

“Too often in the NHS we see examples of patient safety investigations not resulting in learning and improvement. This is a theme that emerges time and time again in cases of avoidable patient harm and major patient safety inquiries.

The introduction of PSIRF presents a significant opportunity to improve the approach to patient safety incident investigation in England. However, if this is to live up to its ambitions, it must have a clear focus on turning insights and learning into action and improvement. The content of early Patient Safety Incident Response Plans suggests that greater work is needed in this area. Plans should have details on how safety recommendations will be monitored and evaluated, as well as including provisions for sharing good practice as widely as possible.

PSIRF is intended to be flexible, with NHS guidance on the creation of Patient Safety Incident Response Plans reflecting this. However, from our analysis we have found that the lack of uniformity in these plans has the potential to complicate cross-organisational comparisons. This in turn could hinder the identification of best practices as Trusts approaches diverge. If we are to understand the impact that PSIRF, we believe a standardised framework for evaluating individual Patient Safety Incident Response Plans is essential.”

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Source: Healthcare Newsdesk, 8 May 2025