New approach to safety incidents will see fewer investigations

Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families.

The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations.

According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework.

NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition.

However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required.

Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”.

However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements.

She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.”

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Source: HSJ, 16 August 202