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Event
Aqua - PSIRF senior leadership webinar
Patient-Safety-Learning posted an event in Community Calendar
untilThis session hosted by the Advancing Quality Alliance (Aqua) aims to help Senior Leaders in the NHS understand the what, why and how of the Patient Safety Incident Response Framework (PSIRF) and what it means in terms of responsibilities, assurance, and review of investigation outcomes (moving from blame towards learning and improvement). This event is aimed at Executive and Non-Executive Directors. Register (Please note, this event will be repeated on 5 December 2022) -
Event
The future of healthcare investigations
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will explore what the future looks like for this critical area of human factors investigation. The presenters will each talk about a different aspect and there will be time for you to ask questions. The future of healthcare investigation: focus on learning and improvement Mark Sujan will talk about the new NHS England Patient Safety Incident Response Framework (PSIRF) which puts emphasis on learning and improvement. You’ll hear about the limitations of existing approaches to learning from incidents in healthcare, which PSIRF tries to overcome. You’ll then find out about the principles of organisational learning for achieving sustainable change, based on the CIEHF guidance. Transition: HSIB to HSSIB and MNSI HSIB’s Deinniol Owens will reveal that in April 2023, the Healthcare Safety Investigation Branch (HSIB) will transition into two new organisations: The Health Services Safety Investigation Body (HSSIB) and the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority. You’ll get insight into the roles of the new organisations and hear about the additional focus on the new powers and opportunities available to HSSIB now that it’s been confirmed in statute by the Health and Care Act 2022. Investigation education: The transfer of knowledge Andrew Murphy-Pittock will explore one of the key objectives of HSIB, which is to transfer knowledge to those undertaking and overseeing patient safety investigations. You’ll find out how HSIB has developed a flexible, agile programme, working with colleagues at PSIRF, to help healthcare organisations on the move away from the Serious Incident Framework to a systems-focused approach to learning, involving those affected by incidents in the process. You’ll also hear about current and future plans for the education programme. Who will this be of interest to? This webinar should be of interest to healthcare professionals, investigators, change managers, process designers and anyone with an interest in patient safety. Register -
Content ArticleThis is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
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Content ArticleThe Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups.
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Content ArticleWest Suffolk is first of a small number of trusts in England that are part of a pilot programme recently launched by NHS Improvement and NHS England called the Patient Safety Incident Response Framework (PSIRF). A national initiative, it is designed to further improve the quality and safety of the care we provide through learning from patient safety incidents. PSIRF outlines how providers should respond to patient safety incidents, and how and when an investigation should be carried out. It includes the requirement for the publication of a local Patient Safety Incident Response Plan (PSIRP), which sets out how trusts will continually improve the quality and safety of the care they provide, as well as the experience which patients, families and carers have when using our services. Find out more about what West Suffolk NHS Foundation Trust are doing.
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Content ArticleThis article in the HSJ explores the challenges in implementing the Patient Safety Incident Response Framework (PSIRF) and looks at how it will help achieve effective learning and improvement. Liz Hackett, health advisory partner at Hempsons law firm, addresses the following questions: Who does PSIRF apply to? How does PSIRF help achieve effective learning and improvement? What is required? Involving patient safety and addressing inequalities The challenge
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Content ArticleOn the 18 October it was announced that NHS Trusts have been given an optional six-month extension to implement Learn From Patient Safety Events (LFPSE). There are a lot of messages being talked about and there has been some confusion over what this means. So, what do organisations need to have in place by 31 March 2023 and what has changed? In this blog*, Radar Healthcare cover some of the key information.
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Content ArticleIn this blog, Melanie Ottewill, National Investigator and Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB), explains how HSIB's work is supporting the NHS to adopt a systems approach to local safety investigations through the Patient Safety Incident Response Framework (PSIRF). She looks at how PSIRF promotes a proportionate response to patient safety incidents, highlights the importance of organisations developing patient safety incident response plans and explores how PSIRF promotes compassionate involvement in patient safety incidents. She also highlights guidance to support staff in planning PSIRF implementation.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
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EventThis national conference looks at the practicalities of serious incident investigation and learning. The event will look at the development and implementation of the new Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) a version of which has now been published. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/serious-incident-investigation-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for a discount code. Follow on Twitter @HCUK_Clare #NHSSeriousIncidents
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
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Community Post
SEIPS & Interactions
Keith Bates posted a topic in Investigations, risk management and legal issues
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As discussed at the network meeting as I can find the relevant folder, this is my simplified approach to SEIPS and open to suggested changes. It's nothing new per se (interactions), just the way I am approaching it at the moment which, as the new world order (PSIRF) moves into play I am trying to test it out in a meaningful way. I have included a simplified example. Regards Keith Understanding System Interactions.pdf -
Content ArticleIf you want to find out what the new Patient Safety Incident Response Framework is all about, and how it will support the NHS to learn and improve, this video provides a helpful introduction.
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Content ArticleNHS England’s Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. You can download the attachment below. Further reading: Applying the After Action Review for the PSIRF – some real life examples
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Content ArticleThis NHS England podcast examines how the application of system-based approaches to learning from patient safety incidents will be vital to the success of the Patient Safety Incident Response Framework (PSIRF). Guests Darren Thorne from the consultancy Facere Melius, Jane Carthey, a Human Factors and Patient Safety Consultant and Laura Pickup from the Healthcare Safety Investigation Branch (HSIB) discuss NHS England's learning response toolkit.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Judy talks to us about the power of After Action Reviews (AARs) to promote learning and bring about lasting improvements in healthcare. She also discusses the opportunity that the new Patient Safety Incident Response Framework (PSIRF) offers to take a more people-focused approach to learning from patient safety incidents. -
Content ArticleA thematic review can identify patterns in data to help answer questions, show links or identify issues. Thematic reviews typically use qualitative (e.g, open text survey responses, field sketches, incident reports and information sourced through conversations and interviews) rather than quantitative data to identify safety themes and issues. Thematic reviews can sometimes use a combination of qualitative data with quantitative data. Quantitative data may come from closed survey responses or audit, for example. These top tips support health and social care staff to carry out thematic reviews, but organisations may take different approaches, depending on the purpose and scope of their review.
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Content ArticleA themed review may be useful in understanding common links, themes or issues within a cluster of investigations or incidents. It will seek to understand key barriers or facilitators to safety using reference cases (e.g. individual datix incidents or previous investigations).
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Event
The NHS Patient Safety Conference
Patient Safety Learning posted an event in Community Calendar
The NHS Patient Safety Conference, in partnership with Patient Safety Learning, is a long-standing virtual and in-person event series that has welcomed over 1500 NHS professionals through its doors. In February 2021, further updates and changes were made to the NHS Patient Safety Strategy. The most significant strategy update is the new commitment to address patient safety inequalities, with a new objective added to the safety system strand of the strategy. This event series provides a timely platform to discuss these changes. Key event topics are run across 3 key pillars: Insight Adopt and promote fundamental safety measurement principles and use culture metrics to better understand how safe care is. Use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. Introduce the Patient Safety Incident Response Framework to improve the response to an investigation of incidents and implement a new medical examiner system to scrutinise deaths. Improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee Share an insight from litigation to prevent harm. Involvement Establish principles and expectations for the involvement of patients, families, carers, and other lay people in providing safer care. Create the first system-wide and consistent patient safety syllabus, training, and education framework for the NHS. Establish patient safety specialists to lead safety improvement across the system. Ensure people are equipped to learn from what goes well as well as to respond appropriately to things going wrong. Ensure the whole healthcare system is involved in the safety agenda. Improvement Deliver the National Patient Safety Improvement Programme, building on the existing focus on preventing avoidable deterioration and adopting and spreading safety interventions. Deliver the Maternity and Neonatal Safety Improvement Programme to support a reduction in stillbirth, neonatal and maternal death, and neonatal asphyxia brain injury by 50% by 2025. Develop the Medicines Safety Improvement Programme to increase the safety of those areas of medication use currently considered the highest risk. Deliver a Mental Health Safety Improvement Programme to tackle priority areas, including restrictive practice and sexual safety. Work with partners across the NHS to support safety improvement in priority areas such as the safety of older people, the safety of those with learning disabilities and the continuing threat of antimicrobial resistance. Work to ensure research and innovation support safety improvement. All organisations are committed to patient safety, but how do leaders ensure that they’re doing all they can to deliver safe and effective care? Join Dr Sanjiv Sharma, Executive Medical Director at Great Ormand Street Hospital for Children, and Helen Hughes, Chief Executive of Patient Safety Learning for a presentation at 9.05am. Dr Sharma will outline their ambitious patient safety transformation journey, how they are designing and delivering an innovative safety systems approach. Embedding Patient Safety Learning’s new standards for patient safety, hear how GOSH’s self assessment has informed the development of prioritised action plans, strengthened governance and leadership engagement and cross organisation collaboration. Helen Hughes, Chief Executive of Patient Safety Learning, will outline why a standards based approach to patient safety is needed and the benefits it can bring. Register -
EventuntilFollowing our Patient Safety Incident Response Framework (PSIRF) introduction webinar on 5 September 2022, this is the first in a series of more practical webinars to support organisations to transition to the new framework. This webinar coincides with the start of the 'discovery' phase, and will cover: Update from the national patient safety team (10 mins). Speakers: Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implementation Look back at the 'orientation phase' with examples of challenges and successes. Speakers: Provider organisation TBC (15 mins) Look forward to the 'discovery phase' with examples of challenges and successes. Speakers: Provider organisation TBC (15 mins) Questions and answers (20 mins) We will continue this series of webinars every two months. About PSIRF The Patient Safety Incident Response Framework (PSIRF) was published in August 2022, setting out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. Organisations are expected to transition to PSIRF within 12 months of its publication, and transition should be completed by Autumn 2023. PSIRF preparation is broken down into six phases to ease transition and provide detail around discrete activities that will set strong foundations for implementing the framework. Register for the event
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Content ArticleIn this blog, Melanie Ottewill, National Investigator and Senior Investigation Science Educator at HSIB, shares some key messages from a recent seminar delivered by Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implementation at NHS England. The seminar looked at the new Patient Safety Incident Response Framework (PSIRF) published in August 2022. PSIRF fundamentally shifts how the NHS responds to patient safety incidents for learning and improvement, promoting a proportionate approach to responding to patient safety incidents. It focuses on ensuring resources allocated to investigating and learning are balanced with those needed to deliver improvement. Melanie describes the cultural shift needed to implement PSIRF so it really makes a difference, and talks about the important of compassionate engagement.
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EventAimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. There will be an extended focus on the role of human factors in patient safety investigation in line with the new National Patient Safety Incident Response Framework (PSIRF). For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/human-factors-in-healthcare or email aman@hc-uk.org.uk Follow on Twitter @HCUK_Clare #HumanFactors hub members receive 20% discount. Email info@pslhub.org for discount code.
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Content ArticleThis blog by global law firm Clyde & Co describes the background to the new Patient Safety Incident Response Framework (PSIRF) and how it will change the way that NHS services will investigate patient safety incidents. The authors offer an overview of the framework, its implementation and who it affects.
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Content ArticleThis letter accompanies the publication of the Patient Safety Incident Response Framework (PSIRF) by NHS England. The PSIRF forms a major part of the NHS Patient Safety Strategy and replaces the Serious Incident Framework (SIF) that has been in place since 2015. It aims to improve safety management across the healthcare system in England and to support the NHS to embed the key principles of a patient safety culture. In his letter, Dr Aiden Fowler, National Director of Patient Safety in England outlines how PSIRF was developed, describes how the transition from the SIF to PSIRF will take place and highlights the tools available to support organisations to implement the changes. The letter is addressed to: NHS trust and foundation trust chief executives, medical directors and nursing directors Integrated Care Board medical directors and nursing directors NHS England Regional Team medical directors and nursing directors NHS England regional direct commissioning leads
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Content Article
This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here
