PSIRF: Systems approach to Learning from Patient Safety Events

Promethean Human Designs

Practical PSIRF training to lead proportionate, systems-based learning responses to patient safety events.

This two-day practical practitioner course is designed for staff who lead or support PSIRF-aligned learning responses and need the knowledge, structure and confidence to respond well to patient safety events.

The course focuses on how to scope and structure proportionate learning responses, gather and synthesise information, apply Human Factors and systems thinking, and produce clear outputs that support learning and improvement. Participants will explore practical tools and methods that strengthen incident response practice and help build a more confident, consistent and proportionate organisational approach to PSIRF.

Through practical exercises and case-based learning, participants will build confidence in using PSIRF documentation and methods, facilitating swarms and After Action Reviews, developing coherent accounts of what happened and why, and engaging effectively and compassionately with staff, patients, carers and families.

This course is ideal for organisations that want to strengthen the quality of learning responses, improve the quality of outputs and actions, and build practitioner capability in incident response and organisational learning.

Why this course matters to organisations

• Builds practitioner capability for staff leading or supporting PSIRF learning responses
• Improves the consistency and quality of incident response practice
• Strengthens the quality of outputs, actions and organisational learning
• Supports a more proportionate, confident and structured approach to patient safety incident response
• Helps organisations embed Human Factors and systems thinking in learning and improvement activity

Who should attend?

This course is designed for practitioners who will lead or support learning responses under PSIRF, including:

• Patient safety specialists
• Governance and risk leads
• Quality improvement leads
• Senior nurses
• Clinical leaders
• Operational managers
• Other clinical and non-clinical staff involved in incident response and learning
• Best suited to participants who already have a basic grounding in Human Factors and systems thinking.

Topics covered

• Human Factors and systems thinking for incident response
• Work as done, Safety-II, and drift to failure
• The NHS patient safety landscape and the place of PSIRF within it
• PSIRF tools and documentation for scoping and planning responses
• Systems tools for learning, including SEIPS and timeline mapping
• Learning response methods, including swarms and After Action Reviews
• Information gathering, interviewing skills and multidisciplinary approaches
• Involving patients, carers and families, including Duty of Candour
• Writing clear, decision-useful outputs
• Additional analytical methods, including task analysis and human reliability analysis
• Just culture, psychological safety and authority gradients

By the end of the course, participants will be able to:

• Lead PSIRF-aligned learning responses using proportionate approaches
• Apply Human Factors and systems thinking to understand how system conditions shape risk
• Use PSIRF documentation and methods to plan, scope and structure a response
• Facilitate swarms and After Action Reviews effectively
• Use systems tools to develop a coherent account of what happened and why
• Gather stronger evidence through effective engagement and interviewing
• Involve patients and families appropriately and compassionately
• Produce clearer, more useful outputs that support improvement
• Promote a just, learning-focused culture during and after patient safety events

Tailoring and follow-up

Examples and activities can be adapted to the organisation’s incident profile, governance arrangements and priority safety themes.

Participants receive:

• A certificate of completion
• A 30-minute post-course support call

Register