Learn: Learnhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/page/3/?d=1Learn: LearnenPatient Safety Incident Framework: Where we are and where we are going Dr Tracey Herlihey (4 July 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/patient-safety-incident-framework-where-we-are-and-where-we-are-going-dr-tracey-herlihey-4-july-2024-r11783/ Opening presentation slide. Click to view or hear the presentation

]]>11783Tue, 16 Jul 2024 09:29:00 +0000Webinar - Patients and PSIRF: changing culture (7 July 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/webinar-patients-and-psirf-changing-culture-7-july-2024-r11759/11759Wed, 10 Jul 2024 09:07:45 +0000SEIPS in maternity film (Epsom and St Helier University Hospitals, 18 June 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/seips-in-maternity-film-epsom-and-st-helier-university-hospitals-18-june-2024-r11768/

 

]]>11768Wed, 10 Jul 2024 16:21:03 +0000NHS England: AAR report template (7 June 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/nhs-england-aar-report-template-7-june-2024-r11610/11610Tue, 11 Jun 2024 14:25:00 +0000Appreciative inquiry case studyhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/appreciative-inquiry-case-study-r11347/11347Thu, 25 Apr 2024 07:07:00 +0000Adopting a quality improvement approach to patient safety incidents (15 March 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/adopting-a-quality-improvement-approach-to-patient-safety-incidents-15-march-2024-r11245/11245Thu, 28 Mar 2024 14:55:00 +0000Proactive governance – the Patient Safety Incident Response Framework (Kennedys, 22 March 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/proactive-governance-%E2%80%93-the-patient-safety-incident-response-framework-kennedys-22-march-2024-r11216/11216Tue, 26 Mar 2024 13:09:00 +0000ELFT Patient Safety Incident Response Framework patient information leaflet (January 2024)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/elft-patient-safety-incident-response-framework-patient-information-leaflet-january-2024-r11212/ 11212Mon, 25 Mar 2024 16:41:36 +0000Application of SEIPS and AcciMap to a patient safety incidenthttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/application-of-seips-and-accimap-to-a-patient-safety-incident-r11143/

The incident

At a recent Patient Safety Education Network meeting, I shared this slide. It was the first meeting of the year and this seemed to meet one of our objectives – to share learning from incidents. In truth, I expected the discussion to last no longer than 10 minutes and there would be minimal involvement. I was shocked that when I checked my watch 40 minutes had passed. 

Screenshot2024-03-13164311.thumb.png.2084d890bc6ceb4649a2ec363e43bb48.png

This incident has been through a case review meeting, colloquially known as a scoping meeting. This consists of a medical lead for scoping, patient safety team representation, divisional governance representation and members of the team that were involved in the incident. It could be viewed as a mini multidisciplinary team review.

During the discussion there was the usual sort of questions: Was it a Patient Safety Incident Investigation (PSII) or a local learning response (LLR)? What tools were used? How was the learning shared? But there was one question that made me stop and think. How can we use this incident to improve the use and understanding of some of the new tools within the Patient Safety Incident Response Framework (PSIRF)? So here goes, hopefully a short piece to help with the application of two tools – Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap).

AcciMap

AcciMap or Accident Mapping is a tool developed by Rasmussen in 1997.[1] It was originally produced to be used in the transport arena and has different levels: (1) Government, legislation and budgeting; (2) Regulatory bodies and Associations; (3) Local Government, company management, planning and budgeting; (4) Technical and operational management; (5) Physical processes and actor activities; and (6) Equipment and surroundings. We have modified it a little and have only five levels.

  1. External factors – NHSE directives, targets, government targets, media influences, Integrated Care Board priorities, pandemics, social circumstances, public awareness and expectations.
  2. Organisational factors/hospital management – included here would be culture, policies, guidelines, change management strategies, pressures to perform, multi-site working and culture.
  3. Technical and operational management (job/workplace factors) – included here will be the individual workplace items such as lack of equipment, tools and technology being used, environment, staffing levels and rotas.
  4. Physical/individual factors – these can be for any of the 'players' in the incident and would include experience, training, skills, tiredness, hunger, emotions, to name a few.
  5. Outcome – poor or good and can be multiple outcomes.

It should be noted that these are not exhaustive lists but more a flavour of what can be covered in each level. I do take the view that there are no wrong 'answers' with an AcciMap and it is more important to get the contributory factors down on the chart, to then be able to examine the interactions. So, what did this look like for the patient safety incident? Something like this:

Screenshot2.thumb.png.3a8704862883a2675c1acb73fcfeb9ec.png

You can now see potential interactions. Let's pick one element of the AcciMap; for example, if we look at how the Nursing and Midwifery Council (NMC) Preceptorship Standards may influence what happened in this incident. The NMC standards may be incorporated into the hospital policy and this in turn may dictate the ideal staffing levels. With these levels sorted out, then adequate support and supervision can be provided to junior staff members. So, there may be some work to see these interactions.

There is an additional negative interaction on the staffing levels, which is from the media focus on maternity units and healthcare in general. These negative headlines could be influencing the recruitment of students to midwifery and nursing programmes, but also the staffing levels may be influencing on where students are applying for jobs when they graduate. There will be many other interactions that require further investigation with other tools, such as observations, Walk Through, Talk Through, and possibly exploration in interviews.

There is a positive outcome throughout all of this, and that is the teamwork and the co-ordination of three specialist teams in the care of the child – ortho, plastics and general surgery. They all came together to offer their expert opinion so, even though we start with a negative outcome, there is a glimmer of hope in the incident. This is shown with the green arrows and box.

Systems Engineering Initiative for Patient Safety (SEIPS)

We can now turn our attention to the SEIPS framework. We need to remember that this is another framework and not an investigative tool in itself. What I mean is that this is a way to highlight potential interactions and how they may affect the processes and outcomes.

Screenshot20243.thumb.png.7adf1e954f4cb9ca24657241e05047cd.png

So if we follow a thread on the SEIPS, we can see that the outcome was influenced by the care process of checking the skin every shift, but in this case there is no record of this. So we may discuss this with the practitioner and ask their level of experience, how they interact with the IT system and if there are enough computers, laptop and desktop or IPADs to record this at the time that it is done. What was there understanding of the sign that states 'Babies are to be nursed with mittens on at all times'? Does this allow for the mittens to be removed to check the skin? What do other members of staff do and understand by this?

I think that both frameworks highlight potential interactions, then you hang other tools on the frame to get into the world of work as done. I imagine as we in healthcare get more used to the tools, that they will evolve and mature.

Actions and next steps

Following this incident, the following changes have been made:

  1. All donated mittens are now checked for loose threads. 
  2. We are looking at whether the use of babygrows with integral mittens would be a more feasible option. Advising parents that this is the best option for their children may reduce the cost pressure on the Trust, whilst ensuring the child gets the requisite protection following the surgery. It would also mean that the parents would get long-term use from the clothing.
  3. The sign on the cot stating the 'must be nursed with mittens on at all times' has been changed to reflect the need for the mittens to be removed to facilitate the skin check, once a shift. 
  4. The information has been shared at the local Medical Devices Safety Officer's forum to inform other local trusts of the risk and the patient safety incident we discovered.
  5. The neonatal team have also shared the event and the learning with the local maternity and neonatal network.

We provided a teaching session to the Patient Safety Management Network, where an AcciMap was written showing how the AcciMap can be used but also highlighting some good practice within the incident, namely the teamwork between three surgical specialities to ensure that the child got the best care possible after the event.

We also turned the multidisciplinary review into a SEIPS approach and provided a small amount of coverage about this. The pleasing aspect of this was the amount of discussion that it sparked. There were some questions and observations that had not been thought about. The discussion showed the value of a team approach with people that are not used to working on the team, who are able to notice the so-called basics that many of us take for granted.

One suggestion that came out from this would be to turn the process of a head to toe check into a hierarchical task analysis, so that may be something we do in the future. 

Reference

1. Rasmussen J. Risk Management in a Dynamic Society: A Modelling Problem. Safety Science, 1997; 27: 183-213.

Further information

Related reading on the hub

We would love to share more examples of how hub members are using the PSIRF tools to learn from a patient safety incident. Share your examples here (you will need to be a member of the hub, sign up is free and easy) or email us: content@pslhub.org. 

]]>11143Wed, 13 Mar 2024 16:49:28 +0000Patient Safety Incident Response Framework supporting guidance: Oversight roles and responsibilities specification (August 2022)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/patient-safety-incident-response-framework-supporting-guidance-oversight-roles-and-responsibilities-specification-august-2022-r10881/10881Mon, 29 Jan 2024 00:00:00 +0000PSIRF and the coronial processhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/psirf-and-the-coronial-process-r10684/10684Wed, 20 Dec 2023 14:50:00 +0000NHS England: Patient safety incident investigation (August 2022)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/nhs-england-patient-safety-incident-investigation-august-2022-r10603/10603Mon, 11 Dec 2023 10:54:00 +0000Patient Safety Incident Response Plan (PSIRP) finderhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/patient-safety-incident-response-plan-psirp-finder-r10372/

Click on the links below to view each trust's PSIRP

We have also started to add PSIRPs from independent healthcare sector providers and registered charities to this list.

]]>10372Thu, 02 Nov 2023 11:30:17 +0000A simple guide to the Patient Safety Incident Response Framework (PSIRF)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/a-simple-guide-to-the-patient-safety-incident-response-framework-psirf-r10538/

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:

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, you can 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.
]]>10538Wed, 29 Nov 2023 09:55:39 +0000Homerton's guide to implementing Learn from Patient Safety Events (LFPSE) into Datixhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/homertons-guide-to-implementing-learn-from-patient-safety-events-lfpse-into-datix-r10539/10539Wed, 29 Nov 2023 10:28:00 +0000Presentation: Learn from Patient Safety Events (LFPSE) Datix guide (September 2023)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/presentation-learn-from-patient-safety-events-lfpse-datix-guide-september-2023-r10442/10442Tue, 14 Nov 2023 12:54:00 +0000Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UKhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/reviewing-%E2%80%98work-as-done%E2%80%99-to-prevent-wrong-site-anaesthetic-blocks-an-interview-with-marsha-jadoonanan-hca-healthcare-uk-r10303/

]]>10303Thu, 19 Oct 2023 13:28:05 +0000PSIRF Risk Register and Risk Management Plan: Free tool to help you transitionhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/psirf-risk-register-and-risk-management-plan-free-tool-to-help-you-transition-r10321/

PSIRF is a significant organisational and culture change programme and organisations need to produce certain documents to show how they are implementing it locally.

This includes a Board-approved Patient Safety Incident Response Plan (PSIRP), outlining their patient safety priorities and how they will adopt the new tools and methods for:

  • incident review
  • staff engagement and training,
  • patient and family engagement 
  • culture change.

To ensure patient safety is at the heart of these implementation plans, they will need to be informed by a risk assessment.

PSIRF Risk Register and Risk Management Plan

Last year, working with members of the Patient Safety Management Network and others, Patient Safety Learning developed a PSIRF Risk Register and Risk Management Plan.

This has been used to support members of the network as they transition to PSIRF.

We have now published an updated version, here on our patient safety platform – the hub, free and available to anyone. It’s a generic risk assessment and has been shared in a format that allows organisations to adapt to meet their local circumstances and priorities. 

This tool is designed to help leaders in the NHS and independent sector implement PSIRF safely.

You can download this by opening the attachment on this page.

Join our community

If you would like to join our global online community of people passionate about patient safety, please sign up to the hub here. It’s free and easy to do.

If you would like to join the Patient Safety Management Network or another safety-focused network, tick the relevant box when you register for the hub.

Our blog 7 reasons to join the hub will give you a flavour of our how becoming a member could benefit you.  

Share your views

Are you involved in the implementation of PSIRF?

  • How has the process been?
  • What has helped you to transition?
  • What tools would help you moving forward?
  • What do you think of the tools shared here by Patient Safety Learning?

Share your thoughts and experiences by commenting below (you’ll need to sign up first for free), or by getting in touch with us at content@pslhub.org.

Related content

]]>10321Tue, 24 Oct 2023 08:25:00 +0000Just Culture in healthcare: The dawn of a new era (HindSight, October 2023)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/just-culture-in-healthcare-the-dawn-of-a-new-era-hindsight-october-2023-r10295/10295Thu, 19 Oct 2023 10:57:00 +0000A brief guide to walkthrough analysis (NHS England, August 2022)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/a-brief-guide-to-walkthrough-analysis-nhs-england-august-2022-r10227/10227Thu, 05 Oct 2023 12:54:00 +0000Is the NHS ready for PSIRF? A blog by Chris Elstonhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/is-the-nhs-ready-for-psirf-a-blog-by-chris-elston-r10184/

In my opinion, PSIRF is one of the biggest changes in patient safety that we have seen in healthcare since the NHS was introduced in Britain.

The historical position has been that the last person to touch a patient or the last process that the patient underwent was the cause of the patient safety incident. The learning has often been focussed on the person: telling them to be more careful, referring them to policies and guidelines. Occasionally, there will be an attempt to make the system safer, but often this is an introduction of a checklist or some statutory training.

The problem with these approaches is that only one person changes their practice and, in several months, that person may have rotated to a new placement or secured a new role, meaning that the learning from the incident disappears with them!

So PSIRF has introduced systems thinking to the NHS. This is where several different factors are examined for their influence on the way that people work: more commonly referred to as ergonomics or human factors.

Every day at work we all make a series of transactions, probably more so in healthcare. We have many different priorities and can flip from a routine situation to an emergency in the space of a few seconds, and back again. There are many different activities that need to be co-ordinated from so many different teams and there are pressures we face daily, not least the well reported industrial actions, poor staffing levels, the recruitment/retention issues and the working conditions.

So why would I think that Trusts and the wider NHS in England are not ready for PSIRF?

We are now being instructed by NHS England to look at the wider context of any patient safety incident. This means looking at the system that we work in. Basically, the NHS is beginning to modernise its approach to patient safety. It has seen the progress that has been made in other industries and has found itself stagnating at the same time as seeing so many scandals enter the press and the public’s thoughts. Many of the scandals repeat similar themes. This shows that the NHS does not learn lessons but repeats the historical mistakes and errors.

So what does looking at he wider context actually mean? A framework has been suggested to Trusts to use, this is the Safety Engineering Initiative for Patient Safety (SEIPS). This is a framework to give areas of interaction that should be looked at. It places the person at the centre of the work system but then shows how various other entities interact with the person. All of which then impacts on the processes and subsequently the outcomes.

Chrisblog2.png.61080625acd05cd4214286eeb58b6ed6.png

What this does is show that the often reported 'blame culture' of the NHS does not understand the complexity of the system. In fact, using SEIPS would suggest that most patient safety incidents are a culmination of factors and events that end with an outcome, either favourable or not.

This means that the executive boards are going to have to pay attention to what is being said in the patient safety incident investigations, and in the learning responses from those patient safety incidents that don’t meet the criteria of a patient safety incident investigation.

For instance, if we look at a drug error, how many times have people asked what is the experience level on the ward? Is the patient being looked after on a specialist ward with staff who have experience in this area or are they an outlier from a specialist ward to a different specialism–for example, a gastro patient on a vascular ward?

A series of transactions

Another factor that needs to be considered is that the work healthcare professionals do is subject to a series of transactions. The individual practitioner must weigh up many different, often competing priorities to achieve their workload. For example, in the emergency department does the observations of a patient that has been in the department for several hours get completed or does the incoming admission from the ambulance service take priority? One has a measurable target (15 minutes to turn the ambulance around), the other doesn’t. This is a good example of internal and external factors influencing decision making.

We can even take the view further afield and look at the interfaces between the GP practice and the specialist service of the acute Trust. This could lead to factors outside the control of the Trust contributing, such as the expectation that GPs will follow up emergency department attendances with regular bloods but receive discharge summaries too late for the follow up, or how the GP is waiting for extended periods on the phone to make a referral which has an impact on their remaining workload.

These processes happen hundreds of times in a shift and often there is no spare staff to do the other process; for instance, in the above example, the observations of the patient that had been in the department for several hours. So the admission is completed and then a patient develops chest pain and needs an ECG, again, the observations are delayed and there is no spare staff to assist. This is not an unexpected event but entirely predictable but staffing levels do not allow for this.

What is the role of the executive board?

So if we are identifying those factors that need to be addressed in the examples above – lack of experience, lack of knowledge, outliers, staffing levels – what does the executive board do? The solutions and ability to mitigate the risks are not wholly within their ability to give. So where does the message go? To the Integrated Care Board (ICB), NHS England or to the Department of Health and Social Care (DHSC)? How can that message be passed up to those higher echelons? There does not seem to be a channel for those communications.

For those events that do not meet the threshold for a patient safety incident investigation and require a local learning response, how is that to be achieved? We are asking those over-worked, under-staffed clinical areas to release a member of staff (often someone senior) to complete the
local learning response. Although there are new tools available to use, many of which will streamline the process of the investigation and mean it is quicker and easier to identify the lessons and frailties in the system, is this an example of another transaction as described above? Does the clinical area release a senior member of staff to complete the learning response and pay bank or agency staff to cover, or do they postpone the learning response? Which often leads to superficial investigation and nothing being learnt or changed – an often cited reason why people do not report patient safety incidents. The Sword of Damocles hangs over our heads every day!

I wonder how many executive bodies are prepared to feedback to NHS England and DHSC that the current mandate to operate at greater than 100% and to reduce a backlog on the waiting list is possibly contributing to the safety incidents, alongside fatigue and the repetitive nature of tasks? Or the lack of beds as we maintain greater than 100% occupancy every day but are expected to maintain a resilience to a major incident, or the increased pressure often attributed to winter but experienced all year round now.

The positives

So this blog seems quite negative but there are some positives to this. Although I don’t think the NHS is mature enough at the moment to adopt PSIRF, there are too many documented cases of risk being identified and not actioned. There is a groundswell of opinion that something needs to change. We know that there is a retention and recruitment issue and in my opinion PSIRF gives us an opportunity to address this.

I think morale would be improved if the workforce feel that their opinion is valued and acted upon – this is very much an avenue that PSIRF can improve. The need to understand the normal and the excellent to influence every day, means that staff can be involved to improve their own areas. Staff will be engaged and proud to tell people where they work, students will have a great placement with motivated and energetic staff, leading them to apply for jobs.

The use of an appreciative style inquiry could lead to unobserved opportunities to be suggested to managers and senior staff. This in turn can lead to greater collaboration between wards, teams, care groups, divisions, Trusts and regions. This could lead to a rapid transfer of ideas across the country.

Ultimately, if we can change the mindset and the culture to one of honesty, transparency and looking for what the data is telling us, then our patients will receive safer and possibly more effective care. A win-win for everyone.

The words of President James Garfield seem particularly apt for healthcare at the moment:

“Most human organizations that fall short of their goals do not do so because of stupidity or faulty doctrines, but because of internal decay and rigidification. They grow stiff in the joints. They get in a rut. They go to seed.” President James Garfield.

I take this phrase to mean that we need to keep trying new, innovating things and, using a military phrase, 'remain rigidly flexible' to adapt, improvise and overcome all the challenges that we face.

I am committed to striving for improved patient safety by understanding the work that we currently do and looking at how the different entities of the system interact. Although I am sure PSIRF is a step in the right direction, I do not think it is the complete journey. This will be a long process, introducing new tools and, more importantly, changing the mindset and the culture of a huge behemoth of an industry.

Let's do this!

Patient Safety Education Network

Chris chairs the Patient Safety Education Network. The network is open to those who teach any element of patient safety or provide learning from patient safety incidents. The network is hosted on the hub. You can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Education Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email support@PSLhub.org.

Read Chris's blog about the Patient Safety Education Network here.

]]>10184Thu, 05 Oct 2023 07:30:00 +0000Achieving a restorative Just Culture through the patient safety incident response framework (20 September 2023)https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/achieving-a-restorative-just-culture-through-the-patient-safety-incident-response-framework-20-september-2023-r10213/10213Tue, 03 Oct 2023 17:54:00 +0000HSSIB: Learning Response Review and Improvement toolhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/hssib-learning-response-review-and-improvement-tool-r10126/10126Tue, 19 Sep 2023 13:41:00 +0000Reflections on PSIRF, patient engagement and why we investigate: a recent discussion at the Patient Safety Management Networkhttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/reflections-on-psirf-patient-engagement-and-why-we-investigate-a-recent-discussion-at-the-patient-safety-management-network-r10065/

Autumn marks the deadline for all NHS trusts in England to transition to PSIRF, so it was fitting that our PSMN meeting on 1st September dealt with some of the key issues the new framework is presenting. Patient safety colleagues from a wide range of organisations shared their reflections, concerns and questions about the complex and pressing issues they are facing as they seek to adopt PSIRF’s new approaches to patient safety incident responses. There were rich discussions about variation in how trusts are implementing the framework, the resource implications of meeting the expectations of NHSE regarding PSIRF, how patients engage with the process and who should work with them.

Perhaps the most important question that was discussed was about the purpose of patient safety investigations—families may have very different ideas to managers or incident investigation teams about why a loved one’s death should be investigated, and that can hugely affect how they respond to and experience the process. 

What are the implications of increasing engagement with families and patients?

PSIRF introduces a range of new approaches to incident investigation, aiming to make the process shorter and simpler, more collaborative and transparent, and easier to implement learning from.  Trusts’ existing patient safety structures and teams will need to adapt to significantly different ways of working under PSIRF. One of the key topics was how to highlight and deal with the consequences of these changes, some of which have been predicted and some of which have possibly not yet been considered by NHS England and individual trusts.

Here are some of the implications that members highlighted:

  • There is a resourcing and capacity issue linked to the increased work involved in engaging with families. For example, some organisations are separating the role of engaging with patients and families from that of undertaking investigations, to reflect different staff positions, experiences and skill sets. 
  • Across some organisations there is a huge gap in family liaison and support, and that extends to PSIRF. This is a significant resourcing issue that needs to be addressed, as without adequate communication and support, investigations can be very distressing for patients.
  • Different ways of working will require changes and updates to trusts’ technology. For example, some trusts are designing trackers to record and monitor engagement with patients and families by multiple staff members. While this should improve communications between staff and patients, trusts may need to invest in digital and other solutions to make sure systems are reliable and that staff know how and when to use them.

Does the language and approach of PSIRF create barriers for patients?

The discussion then moved on to the fact that how we engage with patients and families can compound the harm they have already experienced. Working with harmed patients isn’t easy and needs the right people, equipped with right skills and the right resources. Many members voiced the need for more guidance and training for all clinical staff, as PSIRF means that their role in investigations and patient engagement is changing. For example, some organisations are updating their Duty of Candour policy to reflect the requirements of PSIRF, and these changes will affect all clinical staff. 

During the discussion, several members pointed to incidents where families had found the approach and language of PSIRF difficult, or even offensive.

  • There was some discussion about how the language used is a barrier to patient engagement, with names and descriptions in the framework laden with what is being seen as NHS jargon such as ‘learning leads’ and ‘patient safety partners’. Members pointed out that this language is inaccessible and doesn’t make it easy for patients to understand what’s going on in the investigation process. One member suggested learning from the way the Parliamentary and Health Service Ombudsman has used accessible language in its new NHS Complaints Standards.
  • Several members reported instances where families had found the language of PSIRF insensitive. For example, one family member had told a member of staff, “my mother’s death is not a learning opportunity.” Perceptions that the investigation process is detached from the reality of a person’s lived experience can lead to difficulties in maintaining supportive and positive relationships with patients and families. It highlights a need to consider whether the language used in the implementation of PSIRF is adequately compassionate and respectful.

We also talked about when the best time to involve patients in different PSIRF processes is. For example, one member pointed out that if you involve patients in an After Action Review (AAR) too early on, then you won’t have any answers for them, and this can be frustrating for everyone involved. On the other hand, conducting an AAR without the patient won’t include the patient's direct insight and might be seen as ‘rehearsing the truth’. This can undermine trust in the transparency of the investigation.

We also looked at the resources and literature available for patients engaging with PSIRF, and the general feeling was that there is a big gap here. There is no guidance from families from NHS England, and while some excellent resources have been produced by the Learn Together collaboration, they are quite lengthy, which may put patients off. It was suggested that a summary version of the resources would be a helpful tool to offer patients. 

What’s the purpose of patient safety investigations?

The issues we looked at around the language of PSIRF led on to a broader discussion about why we investigate, and whether PSIRF is aligned with patient views on this. PSIRF places a big emphasis on learning from patient safety incidents, which is clearly vitally important for improving patient safety. However, patients who have been harmed or people who have lost a loved one to avoidable harm are likely to have different reasons for wanting an investigation. The family member previously mentioned, who did not like their mother’s death being referred to as a ‘learning opportunity’, did not see organisational learning as the primary purpose. Patients and families may be looking for:

  • a sense of justice and, in some cases, compensation.
  • compassionate support and clear information on what happened to them or their relative.
  • assurance that changes will be made to prevent future harm. This is a strong motivator for most patients, but it may not be the only reason they want to be involved in the process of investigation.

It was also pointed out that the proportionate approach that PSIRF promotes presents us with a big gulf in the nature and approach we take to patient and family engagement. The level of engagement will depend on the severity and impact of avoidable harm, meaning patients involved in incidents that don’t reach the threshold for a patient safety incident investigation (PSII) may not receive the answers and support they need.  

Staff engagement and support for patient safety specialists

As well as the challenges PSIRF presents in terms of patient engagement, the new framework will also require buy-in from staff right across the organisation. Some members shared concerns about attitudes they had encountered in front line clinicians and patient safety leads. For example, it was reported that some doctors are taking the view that if no AAR is submitted, they don’t need to have a Duty of Candour discussion with patients or families.

One very important question we discussed was what additional support might be needed for staff who conduct investigations or work in patient safety roles. Exposure to traumatic events and awful harm, day in and day out, is painful and causes harm in itself. There is a clear gap here; dealing with patient safety incidents can be emotionally draining, and we talked about the need for clinical supervision and psychological support for staff. At past PSMN meetings we have discussed at length the need to provide support and resources for harmed patients and their families. It is an important area that we will return to at future meetings.

Variation between trusts

The key theme that ran throughout the session was variation in how different organisations are implementing PSIRF. Each organisation’s culture and commitment to patients and family involvement will be an important factor in how PSIRF is implemented. While some organisations have a strong base on which to implement PSIRF patient engagement recommendations, others don’t. Some of the key variations discussed include:

  • different practical approaches to engagement. Some trusts will have informal discussions with families, while others undertake more formal reviews and investigations.
  • a wide range of structures across patient safety teams, with roles carrying different responsibilities from trust to trust.
  • differences in how tools are applied. For example, some trusts are using AARs to assess how effective the investigation process is, while others are using them as a learning response directly. Some trusts are involving patients directly in AARs, while others are using their Patient Engagement Leads as the patient representative in the process.  
  • Patient Safety Partners have different levels of involvement in learning responses.

PSIRF was deliberately designed to allow trusts to adapt their approaches according to their own contexts, which means that variation is an inevitable part of PSIRF implementation. However, members of the PSMN are expressing concern about how this will exacerbate inequities for patients based on where they happen to live—an incident that qualifies for an AAR in one trust may not qualify in others.

Reflections on the way forward

These wide-ranging issues feel like a lot to try and deal with while doing the day-to-day work of patient safety management. But as one colleague pointed out, there has been little funding or training on these complex issues, and members shouldn’t be too hard on themselves. There is a long way to go before PSIRF makes tangible improvements to the methods and outcomes of learning responses and incident investigations, for both patients and staff.

It was highlighted that research and evaluation funding to consider dissemination and implementation is available for another year and members should consider how they might access and use this to look at tackling some of these key issues.

Joining the Patient Safety Management Network

Do you work in patient safety and want to join the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email support@PSLhub.org.

]]>10065Mon, 18 Sep 2023 08:00:00 +0000The 5-stage process: A summary for patient and familieshttps://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/the-5-stage-process-a-summary-for-patient-and-families-r10110/ 10110Fri, 15 Sep 2023 10:08:55 +0000