A simple guide to the Patient Safety Incident Response Framework (PSIRF)

Summary

From Autumn 2023, NHS organisations in England are changing the way they investigate patient safety incidents. NHS England has introduced this new approach, which is called the Patient Safety Incident Response Framework (PSIRF).

NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. However, discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare.

This guide provides information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident.

Content

What is a ‘patient safety incident’?

A patient safety incident is when something goes wrong in a patient’s care or treatment that causes them harm or has the potential to cause harm.[1] This could be anything from being given the wrong dose of medication to getting an infection after surgery.

Patient safety incidents vary in type and seriousness, and the NHS has different ways of describing particular incidents. For example, some very serious incidents are described as ‘Never events’ (things that should never happen if procedures and guidance are correctly followed).[2]

How are patient safety incidents reported and recorded?

Healthcare staff are required to report patient safety incidents. They generally report through their organisation’s incident reporting systems as part of a new service called Learning From Patient Safety Events (LFPSE). When they input information about an incident, they categorise it according to its type and record other relevant information. This allows incidents to be assessed for their seriousness, and a decision made about how to deal with the incident. If certain criteria are met, a patient safety incident response or investigation will be triggered.

Recording incidents also allows organisations to spot trends of harm, learn the reasons why these events happen and put measures in place to stop similar incidents happening again in the same environment, or more widely across the organisation. The learning can also be reviewed and used more widely, locally by the Integrated Care System (ICS) and nationally by NHS England. 

Patients and family members can also record patient safety incidents using the NHS England patient and public e-form, which is currently being further developed. They are encouraged to always report incidents to healthcare staff at the time they are involved in or witness a patient safety incident. This is because just reporting it on the e-form won’t on its own generate local learning or necessarily be reported to each organisation.

How is PSIRF different from the previous investigation process?

PSIRF replaces the previous approach to dealing with patient safety incidents, the Serious Incident Framework (SIF), which was introduced in 2015.

Under the SIF, hospitals were only required to investigate incidents that reached the threshold for being defined as ‘serious’. This sometimes meant that ‘less serious’ incidents were not investigated or learned from. For patients and families, the SIF process could be long and drawn out, and patients sometimes reported feeling ‘shut out’ from investigations. 

PSIRF aims to provide a more flexible, transparent and compassionate approach to learning responses and investigations, focused on understanding the different factors that contributed to incidents and ensuring organisations learn from them. 

NHS England states that the four key aims of PSIRF are[3]:

(*Our explanation of what each aim means)

1. Compassionate engagement and involvement of those affected by patient safety incidents. Listening to patients, families and staff involved in incidents with respect and care and involving them meaningfully throughout the process.
2. Application of a range of system-based approaches to learning from patient safety incidents. Using tools to help understand all the different factors at play that have come together to contribute to the incident.
3. Considered and proportionate responses to patient safety incidents. Making sure the organisation chooses actions that are appropriate to help understand what happened, learn from it and to reduce the risk of future harm.
4. Supportive oversight focused on strengthening response system functioning and improvement. Making sure patient safety managers and leaders help all staff apply the lessons learned from incident reviews and investigations so that the team and wider organisation work in a safer way. Making sure this insight is shared for wider learning in local and national systems.

Which incidents will be investigated under PSIRF?

Each healthcare organisation needs to publish its own Patient Safety Incident Response Plan (PSIRP). This will outline which patient safety incidents should be reviewed and investigated and which approach should be applied in different scenarios.

This document should be available to access publicly on each organisation’s website. If you have issues finding a PSIRP, you can look it up in our PSIRP finder, or contact your healthcare organisation to request a copy. Our PSIRP finder is a work in progress and we are aiming to collect PSIRPs from as many organisations as possible. If you are aware of a PSIRP that isn’t listed in our finder, please contact us so that we can add it.

What practical changes will PSIRF make to how incidents are responded to and how investigations will work?

PSIRF introduces and promotes a wider range of investigation approaches than were used under the SIF. Different tools, approaches and formats may be used in different circumstances, and this will be determined by an organisation's PSIRP.

Some examples listed by NHS England [4] are:

• Patient Safety Incident Investigation (PSII)—an investigation that takes place when an incident or near-miss has significant patient safety risks and the potential for new learning.
• After Action Reviews (AARs)—a technique used to capture learning from an activity or event that has that has gone well or has resulted in patient harm.
• Thematic reviews—which aim to identify patterns in data to help answer questions, show links or identify issues.
• Swarm huddle—this involves staff ‘swarming’ to the site of an incident as soon as possible to analyse what happened, understand how it happened and decide what needs to be done to reduce the risk of it happening again.

Who does PSIRF apply to?

PSIRF applies to all NHS acute, ambulance, mental health, community, maternity and specialised services. It also applies to independent (private) healthcare providers who deliver services under the NHS standard contract. Primary care organisations and GP services aren’t required to adopt PSIRF at this stage, but they may choose to use some PSIRF approaches.

What happens following a patient safety incident?

How long will the investigation take?

Not all patient safety incidents will result in an investigation but, when they do, the length of each investigation will vary. PSIRF aims to reduce the time investigations take, to ensure patients and families get answers more quickly and that actions are taken swifty to reduce future harm.

The time an investigation takes depends on many factors, including:

• the complexity of the incident, including how many people are involved
• the extent of the harm caused
• the approach taken to the investigation
• whether other similar incidents need to be investigated at the same time
• the resources available to the patient safety and investigation team.

Who will talk to patients and families, and when can they get involved?

Hospital trusts and healthcare organisations have dedicated patient safety teams who lead on incident reviews and investigations and ensure learning is applied to improve patient safety. 

Depending on the organisation’s structure, patients and family members may be contacted by a range of different staff, including patient safety team staff, dedicated incident response investigators, patient and family liaison officers, and patient safety managers. 

Patients and family members should be contacted and involved in the process as early as possible and are likely to be asked for their account of what happened and how the incident has affected them.

Sharing concerns about the PSIRF process

If a patient or family member has concerns, they can raise these with the department where they are receiving care or through an organisation’s Patient Advice and Liaison Service (PALS), which offers confidential advice and support, including information about how to make a complaint. They can also contact the organisation’s patient safety team about patient safety concerns, for example, if an incident isn’t being investigated but they think it should be.

Where can I find more information about PSIRF?

At Patient Safety Learning, we produce and share a range of resources about PSIRF which are primarily aimed at healthcare professionals. They may also be helpful to patients and members of the public who would like more in-depth information about processes and tools. A good place to start is our PSIRF ‘Top picks’ articles:

• Top picks: PSIRF insights and opinions
• Top picks: PSIRF tools, templates and resources

The NHS England website has extensive information about PSIRF, including guidance on how healthcare organisations should work with and include patients and families in investigations.

The Learn Together collaborative has produced a range of resources to help patients understand PSIRF and how they might be involved in patient safety investigations. 

If you still have questions or would like to share your views on PSIRF, start a conversation in our community area or comment on this blog (you will need to join the hub for free first).

Share your experiences with us

We would love to hear about your views and experiences of PSIRF:

• If you are a patient or healthcare professional who has been involved in a PSIRF investigation, what was your experience like?
• What other questions do you have about how incidents are dealt with in the NHS?

References

1. Report a patient safety incident. NHS England website, last accessed 23 November 2023.
2. Never events. NHS England website, last accessed 23 November 2023.
3. Patient Safety Incident Response Framework. NHS England website, last accessed 20 September 2023.
4. Patient safety learning response toolkit. NHS England website, last updated 17 August 2023.