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The Patient Safety Incident Response Framework

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Hi

The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else:

https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/

I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented?

Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues? 

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Hi Jon

I've heard directly from Aidan that there won't be an implementation plan as such for the NHSI PS strategy, they're just getting on with it. Aidan says they are reporting back through the National Quality Board. I met with Ted Baker this morning from CQC, he jointly chairs the NQB. I said there were a lot of interested people in the service (clinicians, ps and risk managers in providers and commissioners) who want to know what the NHSI PS strategy implementation means for them and in particular the incident framework. 

I'd also heard at a meeting with @Amelia from Browne Jackson that the framework will be released to pilot sites only at this stage and only wider after pilot evaluation. 

Would love to know more if anyone else has any insights to share.

Thanks for raising Jon, sorry I can't help more with the answers.

Helen

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Hi both

I don't have any further information to add to this but I agree that it will be good to hear from the early adopters about how the introductory version of the PSIFR is working in practice,

My understanding is that the first draft of the PSIRF was originally due to be published Autumn 2019 but the timeframe for publication and implementation of the final version has been pushed back to enable the early adopters to report back on their experiences. Whilst the delay may seem frustrating, I think it is a good idea to await the feedback from the early adopters so that the finalized PSIRF is capable of successful implementation and also that it achieves proportionate and effective learning following incidents, facilitating better support for staff involved and improving patient safety.

Amelia

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The introductory version has been published today here with guidance below:

https://improvement.nhs.uk/resources/patient-safety-incident-response-framework/

"Introductory version of the PSIRF

While we are not asking organisations other than the early adopters to transition to the PSIRF yet, we want to help providers outside of the early adopter areas to plan for this change. We have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021.

Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework."

 

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There is much that is well intentioned in this framework. I think there is much that will not achieve the aims and may result in serious unintended consequences. I'm drafting a blog to kick off discussion.  

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What are the unintended consequences and risks of failure that you foresee? 

I think it's positive that they are piloting this and intend to make changes based on experiences from the early adopters. My main concern is that in order to drive up quality of investigations you need to professionalise investigation and have much more rigorous training. Can organisations currently churning out poor quality investigations make a step change to something much better? Will there be a national commitment to support that? A national patient safety syllabus, patient safety specialists and accredited list of trainers all seem steps in the right direction. However I think real improvement would need sustained support and focus and some national / regional coordination. If trusts are left to get on with it you'll end up with same mixed bag we have now

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So much for my blog, I just haven't got round to writing it. Small issue of being distracted by other issues and indeed, Covid.

My main concern is that, as I understand it, NHS organisations will assess whether there is value in undertaking an investigation for learning. If they feel that the incident has happened before, and been amply investigated, they may chose to take no action. But how do they know that there's no new learning unless the undertake an investigation? And if there was learning, then was this applied successfully - maybe not if the incident/harm was repeated?

The unintended consequence that gives me most concern is the potential impact on patients and family members. If there's harm and yet the organisational response is that no investigation is needed, how will patients and family members feel about this? Will they consider that the Trust has complied with their legal duty of candour? Will they feel that in order to get answers as to what happened and why and to get redress, they need to make a formal complaint? Will they be offered a mediation approach and if so, how will this be informed if there is no investigation? Will this frustrate families into a more litigious approach?

It will be very interesting to hear from the pilot Trusts and CCGs as to whether this has been an issue for them. And if so, what their advice would be to NHSE/I?

And have patient organisations been engaged for their views?

What do others think?

Helen

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Hi Helen

My understanding of the guidance is that in-depth investigations will be limited to incidents of greatest severity and potential for learning. To support this organisations will have to develop an investigation strategy which defines what they would prioritise for investigation which links to national priorities too. There will be scope for organisations to investigate incident types that aren't in their priority list but idea is they focus on areas of highest risk. So, in reality the most severe forms of incident would still trigger an in-depth investigation. 

For less severe / lower priority incidents alternative forms of investigation or review could be used, especially where there is a quality improvement programme linked to that area of work. So, for example, if a trust has a comprehensive improvement programme related to reducing occurrence of pressure ulcers and previous investigations have shown similar causes which they are focusing on addressing then the idea would be to spend more time on improvement than investigating to find same causes. I think the idea is that trusts do too many investigations of poor quality with a RCA conveyor belt approach and their should be fewer high quality investigations undertaken by staff with specialist skills. 

In terms of patient and family engagement there is a stronger focus on that in new framework. It is also intended to facilitate better cross system investigation too by CCGs and NHSE&I playing a coordinating role. 

There certainly is an industry of Serious Incidents at the moment and this is intended to move away from that. I think there is potential for this not to deliver everything it is aiming for but the status quo isn't really delivering so I welcome the new framework. I think the key will be effective implementation and support / coordination and willingness to adapt and refine the framework based on assessment of how it is working in practice

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Hi ,

I am new to patient safety management, after 25 years working clinically it has been a learning curve.  

I have seen RCA reports, some poor reports that need to be re written and many good ones too.  This takes up a huge amount of time by many different people of differing roles.  Co-ordinating meeting, feedback and discussion can take time and hold up actions for dissemination.

There is much effort put into severe and moderate harm, internal RCAs where it is not a serious incident but it doesn't warrant a serious incident investigation.

However,  the very low/no harm incidents don't get much of a look in (there are tonnes of them!)  If you take a look at the 'accident triangle ' (which I am sure you will be aware of ) - near misses and no harm happen the most frequent and may often lead to the more serious incidents if left.  I would suggest much more emphasis, effort needs to be directed into the no harm/near miss incidents.  They may seem petty and not sexy, like an SI - but they are great indicators of when the next SI may appear.

An over sight of all no/low harm incidents with thematic problems highlighted and then fed into either a local (ward, department) or Trust wide QI project would be a fantastic way of changing practice from the 'ground up'.

Capability of ALL staff trained in QI is happening in Trusts but not all Trusts.  It would be a fabulous question for the CQC lines of enquiry 'how many staff are trained in QI?'  This can be linked to well led and safety, but thats a whole other subject!

As I mentioned, I am new to this role, but these are my observations so far.

 

Claire

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Thanks @Jon Holt I was really taken by your comment 'I think the idea is that trusts do too many investigations of poor quality with a RCA conveyor belt approach and their should be fewer high quality investigations undertaken by staff with specialist skills. ' Think that resonates with @Claire Cox too. And the opportunity to use insights from near misses/patient feedback/low harm events to lead to improvement. 

Will be fascinating to hear the outcome of the pilots and how the framework can be implemented so that we maximise the value for learning and action. And of course we'd love to be able to share the (suitably anonymised) learning and action on the hub.

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