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The Patient Safety Incident Response Framework

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


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.


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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.


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


"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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