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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. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register

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. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Peter Ledwith, Deputy Director of Governance, East Cheshire NHS Trust Liam Oliver, Senior Patient Safety Manager, Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board Register

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. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Paul Chandler, Head of Patient Safety & Quality Assurance, Patient Safety Specialist, PSIRF Lead, Royal Hospital for Neuro-disability Lesley McKay, Associate Chief Nurse for Infection Prevention and Control, Warrington and Halton Teaching Hospitals NHS Foundation Trust Register for the webinar

Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tracey talks to us about how her love of applying psychology led to her role in patient safety, the importance of putting users at the centre of developing the Patient Safety Incident Response Framework (PSIRF), and what we can learn from magicians about patient safety.

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.

This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.

We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce. Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past. There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF). 

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing their insights, opinions and reflections around PSIRF to support one another at this time of transition.   In this ‘Top picks’, we’ve selected ten to share with you.* 

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing PSIRF resources, tools and templates to support one another as the approach is implemented. In this ‘Top picks’, we’ve selected some to share with you.* 

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Ashley talks to us about the need to professionalise patient safety roles while also upskilling frontline healthcare staff to improve patient safety, describing the role that professional coaching can play. He also discusses the challenges we face in understanding how AI affects decision making in healthcare and how it could contribute to patient safety incidents.

This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. Knowing things may have gone wrong can feel a heavy burden and a complex emotional situation to be managing. Often, we avoid visiting difficult emotions in others, as well as ourselves, because we don’t feel confident or skilled, or we feel fearful of not doing it perfectly. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members will receive 20% discount. Email info@pslhub.org for a discount code.

This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: Task analysis Cognitive overload Reliability Non-technical skills Examples Register hub members receive 20% discount. Email info@pslhub.org for discount code.

This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider work stream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.

The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. This national conference looks at the practicalities of Serious Incident Investigation and how this has changed with the publication of PSIRF. The conference will also update delegates on best practice in serious incident investigation under PSIRF and ensuring the focus is on safety actions for improvement. There will also be an extended focus on learning, including mortality governance and learning from deaths ensuring insight and investigation findings lead to improvement. The conference will include updates from PSIRF early adopter sites. The conference update delegates on the new Patient Safety Incident Response Standards and how to review your current practice against these standards. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/serious-incident-investigation-patient-safety or email kerry@hc-uk.org.uk Follow this conference on Twitter @HCUK_Clare #NHSSeriousIncidents hub members receive a 20% discount. Email info@pslhub.org for a discount code.

This conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to ensure patient feedback is translated into quality improvement and assurance. Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. Sessions will include learning from patients, improving patient experience, practical sessions focusing on delivering a patient experience based culture, measuring patient experience, using the NHS Improvement National Patient Experience Improvement Framework, demonstrating insight and responsiveness in real time, monitoring and improving staff experience, the role of human factors in improving quality, using patient experience to drive improvement, changing the way we think about patient experience, and learning from excellence in patient experience practice. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-insight or email aman@hc-uk.org.uk Follow on Twitter @HCUK_Clare #PatientExp hub members receive a 20% discount. Email info@pslhub.org

This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register

This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register