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  • PSIRF infographic: A new era in patient safety for the NHS and healthcare

    • UK
    • Infographics
    • New
    • Health and care staff, Patient safety leads


    Stephen Ashmore and Tracy Ruthven, Co-Directors of Clinical Audit Support Centre Limited, have created a simple, eye-catching poster to explain the new Patient Safety Incident Response Framework (PSIRF). Here they explain why they created the graphic. You can download the poster by clicking on the image or downloading it from the attachment at the bottom of the page.


    The NHS and healthcare love acronyms. Indeed, if you have an interest in patient safety (and let’s face it, who doesn’t?) acronyms are everywhere. We have PSIIs, LFPSE, PSPs, SIF, AAR, HSIB, GIRFT, CIEHF, TRIM, SEIPS and PSIRF, to name just a few!

    Focusing on that last five letter acronym: PSIRF – which stands for the Patient Safety Incident Response Framework. Five words, thirty-eight letters. Jargon. However, PSIRF is undeniably different and represents a sea of change in patient safety, heralding a new era of how organisations will be expected to keep patients safe and respond to incidents. The accompanying literature tells us that PSIRF is ground-breaking and that it represents, arguably, the greatest change in patient safety culture since the inception of the NHS in 1948.

    Obviously given its importance, PSIRF is not something that has sprung up overnight. In 2018, all NHS organisations were asked to take part in a far-reaching consultation looking at patient safety. The researchers, analysts and experts crunched the data and assessed the feedback, culminating in the publication of the NHS Patient Safety Strategy in 2019. Before PSIRF was rolled out to the NHS nationally, the NHS decided to test the new framework out on around 20 early adopter sites. This ‘testing phase’ helped inform and shape the future of PSIRF before the formal documents were published in August 2022. Since then, all NHS Trusts have been working to embed and implement PSIRF by the end of 2023. This is a challenging timeframe, with lots to be done. To meet the challenge, Trusts have created new roles and new posts and invested significantly in PSIRF.

    This brings us onto the graphic that we created. While many of us had waited patiently during 2022 for the PSIRF publications, what immediately became clear in August 2022 was the sheer scale of PSIRF. On 16 August 2022, around 20 PSIRF documents landed totalling well over 400 pages of, often quite technical, literature. Although this information was backed-up with useful quotes and soundbites from NHS leaders and a few insightful four-minute films, we felt there was a need to create a simple eye-catching document that simply explained PSIRF.

    Work on the graphic commenced almost as soon as the PSIRF documents dropped in August 2022. We read as much of the formal literature as we could in August, looked at articles from key leaders and a range of organisations, scanned Twitter and spoke to our friends and colleagues working in the field to see what themes stood out for them. Prior to creating the poster, we had received very positive feedback on a couple of similar graphics we had created for the clinical audit community so we determined that we should keep the format the same.

    In the first instance, nine themes stood out and we asked our illustrator, Amy, to create simple and memorable images. Once the poster had been checked we uploaded this onto Twitter and likes immediately started to rack up. As with any work we do, we encouraged feedback and within four weeks it was clear that we should extend the poster to incorporate a total of twelve images not nine, so we added ‘supportive oversight’, ‘expert investigators’ and ‘psychological safety’.


    Simultaneously, while re-designing the poster in Autumn 2022, we ran and attended several online events where it became evident to us that many healthcare staff outside of patient safety and risk teams lacked a basic understanding of PSIRF. For PSIRF to reach its full potential ALL staff working in healthcare must understand the fundamentals of the framework and it has been pleasing to see that the feedback on the poster has been positive, with many telling us that the graphic helped them understand and want to find out more about PSIRF.

    Overall feedback has been positive – we have been surprised and delighted that Trusts have asked to use or adapt the original poster. We did encounter one co-ordinated series of tweets in January 2023 implying that we had taken the important topic of patient safety and turned it into a cartoon! We take all feedback seriously but after consulting with key leaders we were encouraged to retain the poster in its current format.

    As PSIRF celebrates its first birthday in August 2023, we are considering making a few tweaks to the original design. Our aim was to create an eye-catching and easy to understand poster explaining what PSIRF represents. We know how busy healthcare staff are and that most have limited time at their disposal, even when it comes to learning about major initiatives such as PSIRF. Hopefully the poster has helped and sparked further interest.

    Stephen and Tracy are happy for you to download and share the poster within your organisation as long as it is not amended. Also, keep a look out for version two in the Autumn.


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    Awesome  poster👌 Looking back to 2012 when  there was  a never  event of a retained swab in a breast wound, I am now seeing  this poster for the first time and realize that I dealt with it using some if not all of the framework as follows-
    - Decided on a           different   way of counting swabs
    - A new system to make the change 
    - Researched my idea on Internet and AFPP journals 
    - Made a plan and     discussed it with  my manager for approval
    -  Brought in company reps to teach staff new system
    - Gained the support and cooperation  of staff to use new system

    - Later, involved staff to do audits on new change

    - Change  benefited both  patients 
     and staff  safety.

    Swab safe management to prevent retained swabs - Improving systems of care - Patient Safety Learning - the hub.PDF

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