What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations?

Summary

From Autumn 2023, NHS organisations in England began to change the way they investigated cases of avoidable patient harm and near misses, introducing the Patient Safety Incident Response Framework (PSIRF). As part of PSIRF, organisations are required to create and publish a Patient Safety Incident Response Plan.

This blog summarises the findings of a new report, Patient Safety Incident Response Plans: An analysis and reflection by Patient Safety Learning. Drawing from a sample of 13 Patient Safety Incident Response Plans, the report considers what they can tell us about the implementation of PSIRF.

Content

PSIRF

When something goes wrong with a patient’s care or treatment that causes them harm, or has the potential to cause harm, healthcare staff are required to formally report these incidents. Subsequently, investigations take place into these events, which can act as an important source of insights and learning. These investigations provide an opportunity to identify what went wrong and the actions needed to prevent a similar incident from taking place in the future.

In England, the NHS has recently introduced a new approach to these investigations called PSIRF. This represents a significant shift in the way the NHS responds to patient safety incidents and is intended to be a major step towards establishing a systems approach to patient safety in the NHS. A systems approach is one that focuses on understanding how different parts of the healthcare system interact, rather than placing blame solely on individuals when things go wrong.

Patient Safety Incident Response Plans

As part of PSIRF, NHS organisations in England are required to create and publish a Patient Safety Incident Response Plan. These plans should specify the methods an organisation intends to use to maximise learning and improvement, and how these will be applied to different patient safety incidents. They provide an opportunity for organisations to demonstrate to patients, staff and the wider public how they are seeking to improve patient safety through incident investigations.

In our new report, we have analysed a sample of 13 Patient Safety Incident Response Plans (a sample size of 6% out of the 206 organisations included in our Patient Safety Incident Response Plan Finder). Our intention has been to reflect on what these tell us about the implementation of PSIRF, identify issues that could help organisations update their plans in the future and take action to reduce avoidable harm.

Report findings

From the sample of Patient Safety Incident Response Plans we analysed, our new report has identified a number of key themes:

Variations in approach

Although NHS Trusts use a common template to create their Patient Safety Incident Response Plans, their approach to completing these has varied significantly in places.

An example of this is the criteria organisations use when deciding to conduct a formal Patient Safety Incident Investigation (PSII). There are some patient safety incidents, such as those classed as a ‘Never Event’, where a PSII must be carried out. However, for incidents where there is no national requirement to do so, Trusts decide whether to carry out a PSII based on their own criteria.

In our analysis, we found that in some cases Trusts provided a detailed explanation of factors that they would consider in deciding on whether to undertake a PSII; however, in other plans only a brief explanation was provided. In a few cases, there was no statement on when a PSII would be required.

Differences in detail

While Trusts in the sample we examined all sought to meet the requirements NHS England set them for their Patient Safety Incident Response Plans, the level of detail they have provided differs considerably.

An example of this can be seen when organisations detail how they have identified local patient safety priorities. Patient Safety Incident Response Plans contain both national and local priorities. While NHS Trusts are required to adopt a standardised approach to national priorities, local priorities vary from organisation to organisation.

In our analysis, we found that in some cases Trusts had provided a significant amount of detail of the sources they used to identify local priorities and also included the methodology they used in prioritising these sources. Other organisations, however, provided significantly less detail—in some cases just a brief list of priorities and data sources.

Critical information gaps

We also identified a range of issues that Patient Safety Incident Response Plans in our sample either covered very briefly or not at all. This included:

• Compassionate engagement and the involvement of those affected by patient safety incidents. Detail on this was largely absent in plans, despite this being identified as one of the four key aims of PSIRF.
• Evidence of the existence of robust mechanisms to ensure that safety recommendations are actioned and monitored effectively.
• References to sharing learning and insights from patient safety investigations more widely for system-wide improvement.

Recommendations

Based on the findings in our report, we have identified five recommendations for NHS England and the Department of Health and Social Care. These are intended to improve the approach to creating and implementing Patient Safety Incident Response Plans.

1. Develop a national standardised framework for evaluating individual Patient Safety Incident Response Plans.
2. Create a central NHS repository of Patient Safety Incident Response Plans and Policies.
3. Consider the benefits of introducing independent external reviews of Patient Safety Incident Response Plans.
4. Update Patient Safety Incident Response Plan guidance for NHS and Foundation Trusts so this explicitly refers to sharing insights and learning from the implementation of plans.
5. Commission a full evaluation of Patient Safety Incident Response Plans.

We also highlight some key issues that we believe NHS Trusts should consider when it comes to reviewing their Patient Safety Incident Response Plans:

• Transparency: Trusts should seek to ensure plans are accessible and clearly communicate how approaches are developed, how they impact patients, staff and the public, and how they address patient safety incidents.
• Investigation quality: To help improve the depth and rigor of investigations, there should be a greater emphasis and understanding of the contributory factors to incidents in these plans.
• Quality improvement: Trusts should identify issues that lead to tangible actions to  enhance patient safety.
• Knowledge sharing: How plans can help to facilitate widespread dissemination within organisations and encourage sharing across the health system in England.
• Standardisation of prioritisation: Explore whether a standardised approach—such as outcome-based, contributory factor-based, or a combination of both—could provide a system-wide perspective for reporting and analysis.

Commenting on the report, Patient Safety Learning's Chief Executive Helen Hughes said:

“Too often in the NHS we see examples of patient safety investigations not resulting in learning and improvement. This is a theme that emerges time and time again in cases of avoidable patient harm and major patient safety inquiries.

The introduction of PSIRF presents a significant opportunity to improve the approach to patient safety incident investigation in England. However, if this is to live up to its ambitions, it must have a clear focus on turning insights and learning into action and improvement. The content of early Patient Safety Incident Response Plans suggests that greater work is needed in this area. Plans should have details on how safety recommendations will be monitored and evaluated, as well as including provisions for sharing good practice as widely as possible.

PSIRF is intended to be flexible, with NHS guidance on the creation of Patient Safety Incident Response Plans reflecting this. However, from our analysis we have found that the  lack of uniformity in these plans has the potential to complicate cross-organisational comparisons and learning. This in turn could hinder the identification of best practices as Trusts’ approaches diverge. If we are to understand and evaluate the impact of PSIRF, we believe a standardised framework for evaluating individual Patient Safety Incident Response Plans is essential.”

Share your experiences and views with us

Are you involved in your NHS Trust’s plans to review its Patient Safety Incident Response Plan in the near future? What issues are you considering as part of this process? What do you think is needed to deliver this?

We would welcome your reflections on the issues raised in the report and are keen to hear further insights from those involved in shaping and delivering Patient Safety Incident Response Plans.

You can comment below (sign up to the hub first, for free) or email the team directly at [email protected] to share your experiences.