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Content Article
The Response Study
Patient_Safety_Learning posted an article in Patient Safety Incident Response Framework (PSIRF)
In August 2022, NHS England launched a new way of responding to safety events, called the Patient Safety Incident Response Framework (PSIRF). The PSIRF policy aims to support NHS organisations to be more flexible in how they respond to safety events. The Response Study is funded by the National Institute for Health and Care Research (NIHR). The aim of the Response Study is to understand, in real time, how the roll out of this new policy happens across the NHS in England, and what impact it has. The study is based at the University of Leeds. It began in May 2022 and will end in July 2025. The Response Study are inviting all PSIRF Leads from NHS Trusts and Integrated Care Boards in England to complete a survey by 15 December 2023. To access the survey please contact responsestudy@leeds.ac.uk. -
Content ArticleIn rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
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Content ArticleChris Elston, Patient Safety Education Lead, University Hospital Southampton, shares with the hub his Trust's Patient Safety Incident Response Framework (PSIRF) frequently asked questions. Please feel free to adapt and share at your own organisation.
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Content Article
To mark this year’s World Patient Safety Day (WPSD), the Royal College of Surgeons of Edinburgh (RCSEd) will be running a series of blogs and Talking Heads on key surgical and dental topics in this area. These have been provided by patients, families and carers, alongside members of the College’s Patient Safety Group, College Council and the wider College fellowship. The College’s eleven Surgical Specialty Boards (SSBs) have been asked to provide blogs on how patient involvement in their individual specialty has helped to drive up standards of care. The blogs will provide examples of how patients and carers can play vital roles in making decisions about their own individual care and also how they can enhance the safety of the healthcare system as a whole by contributing to strategic decisions at organisational level. Two blogs will be released on each day of the College’s week-long WPSD campaign, starting on Monday 11 September and leading up to WPSD on Sunday 17 September. Members and Fellows will have access to these through the College website following the campaign. -
Content ArticleLearn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. The resources have been designed, together with people who have experienced patient safety incidents and investigations, to provide the information and support patients might need following a patient safety incident. Information is provided in a range of formats including downloadable guides, videos and infographics. The site also provides information and resources for engagement leads. Learn Together is a partnership between Sheffield Hallam University, the University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford District Care NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, and is funded by the National Institute for Health and Care Research (NIHR).
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Content ArticleThis guide developed by Learn Together and Bradford Teaching Hospitals NHS Foundation Trust has been designed to help patients and families understand what to expect from patient safety investigations and how they can be involved in the process. It includes quotes and advice from patients who have been through patient safety investigations and spaces to record experiences, questions and reflections. The guide provides an outline of the investigation process, broken down into five stages: Understanding you and your needs Agreeing how you work together Giving and getting information Checking and finalising the report Next steps
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Content ArticleRecording of a recent RLDatix and NHS England webinar on Learn from Patient Safety Events (LFPSE).
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Content Article
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.- Posted
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Content ArticleFrom September 2023 all organisations who previously reported to NRLS should make the switch to recording to the new Learn from Patient Safety Events (LFPSE) service, which will replace the NRLS. From Autumn 2023 organisations will also make the transition from the Serious Incident Framework (SIF) to the Patient safety incident response framework (PSIRF). This means there will be changes to the expectations and processes associated with recording information about the response to patient safety incidents This document provides detail into where incident responses are to be recorded during the transition to LFPSE and PSIRF.
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Event
SEIPS in radiology
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in radiology. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS masterclass in healthcare
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in healthcare. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Morning session: 9.30-12.30 Afternoon session: 1.30-4.30 Register -
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SEIPS in social care
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Social Care. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS in mental health
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Mental Health. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS in learning disability
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Learning Disability. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
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SEIPS in surgery
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS surgery. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
Content ArticleThis guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
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EventuntilThis popular training day covers the must do’s and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices £245 (plus vat) per person Discounted rate for bookings of 3 or more: £220 (plus vat) per person Book a place Watch introductory video about the course
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Content ArticleThis NHS dentistry and oral health update has a special focus on patient safety. It includes an introduction by newly appointed Interim Chief Dental Officer (CDO) for England, Jason Wong and covers the following topics: Quality and safety in dental care Contributing to patient safety learning Using the Learning from Patient Safety Events (LFPSE) service Patient safety incidents and harm Patient Safety Incident Response Framework (PSIRF) Spotlight on Project Sphere Regulatory support Clinical leadership in patient safety
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Content ArticleThis guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content ArticleA recent paper (from clinicians and Human Factors specialists at the Royal Surrey NHS Foundation Trust) jointly supported by Elsevier and BJA Education clarifies what Human Factors (HF) is by highlighting and redressing key myths. The learning objectives from the paper are as follows: Identify common myths around HF Describe what HF is Discuss the importance of HF specialists in healthcare Distinguish the importance of a systems-based approach and user-centred design for HF practice. It explains that HF is a scientific discipline in its own right, a complex adaptive system very much like healthcare. Its principle have been used within healthcare for decades but often in an informal way. A link to the summary of the article on Science Direct and further links to purchase the paper can be found here: https://www.sciencedirect.com/science/article/abs/pii/S2058534923000963?dgcid=author
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Content Article
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The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward.- Posted
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Key to the success of the Patient Safety Incident Response Framework (PSIRF) is working collaboratively across organisations utilising the skills of colleagues from different departments This podcast, hosted by Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England, aims to further progress the conversation with special guests: Liz Maddocks-Brown, formerly NHS Horizons Claire Cox, Andy Wilmer and Lorraine Catt from Kings College Hospital Stefan Cantore from Sheffield University Management School. -
Content ArticleThe Patient Safety Incident Response Framework (PSIRF) supporting guidance “Engaging and involving patients, families and staff following a patient safety incident” presents the moral and logical arguments for engaging with those affected by a patient safety incident and involving them in a learning response. This article builds on the guidance given to describe how After Action Review (AAR) can be used to ensure patients and their families and carers can and do make a significant and meaningful contribution to the learning process.
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Event
Applying PSIRF in infection prevention and control
Sam posted an event in Community Calendar
untilOverview: The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. This workshop will focus on applying PSIRF within Infection Prevention and Control (IPC). Audience: All PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. This webinar will focus on PSIRF in IPC. It is recommended for Directors of Infection Prevention and Control, IPC practitioners, IPC Doctors, Microbiologist, pharmacists and patient safety leads. Presenters: Tracey Herlihey – Head of Patient Safety Incident Response Policy, NHS England Rosie Dixon – Regional Head of IPC North West , NHS England Ruth Henein – Head of IPC and Aimee Joyce –Data and Information Co-ordinator, Northumbria-healthcare NHS Foundation Trust Sharon Edgell – ICB System Lead for IPC, NHS Surrey Heartlands ICB Register -
Content ArticleAn opportunity to connect virtually with health and care professionals from across the UK and Ireland on your shared interest in patient safety and quality improvement. An initiative from Supporting Q Connections programme.
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