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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. 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 [PSIRP] 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. Develop a national standardised framework for evaluating individual Patient Safety Incident Response Plans. Create a central NHS repository of Patient Safety Incident Response Plans and Policies. Consider the benefits of introducing independent external reviews of Patient Safety Incident Response Plans. 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. 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.

On Wednesday 15 October 2024, the Department of Health and Social Care announced an independent review of patient safety across the health and care landscape in England. This blog sets out Patient Safety Learning’s response to this announcement. Today the Government has published the terms of reference for a review of patient safety across the health and care landscape. This review will: “… assess whether the current range and combination of organisations delivers effective leadership, listening, learning (including investigations and their recommendations) and regulation to the health and care systems in relation to patient and user safety (and to what extent they focus on the other domains of quality).”[1] This follows on from the publication of Dr Penny Dash’s latest report highlighting significant failings at the Care Quality Commission (CQC), the independent regulator of care providers.[2] The main focus of the review will be on the following organisations: CQC – including the Maternity and Newborn Safety Investigations programme National Guardian’s Office Healthwatch England and the Local Healthwatch network Health Services Safety Investigation Body (HSSIB) Patient Safety Commissioner for England NHS Resolution (patient safety-related learning functions only, not clinical negligence functions). The review will focus on how these bodies work together, with the findings feeding into the government's 10-year plan for the NHS, expected to be published in the spring next year. Patient Safety Learning welcomes this announcement and sets out some initial reflections on this below. A fragmented landscape The landscape of organisations with patient safety roles and responsibilities is fragmented and lacks coordination. This makes it often ill-suited to tackling complex systemic challenges to patient safety. This is an issue we highlighted in our report last year, The elephant in the room: Patient safety and Integrated Care Systems.[3] Therefore, we welcome any steps to promote cross-organisational working and coordination between regulators, ultimately with the aim of reducing avoidable harm. Figure 1: Patient safety environment in England The need to review roles and remits of patient safety organisations in England is not a new issue. The CQC itself referred to this as early as 2018, in their report Opening the door to change: NHS safety culture and the need for transformation.[4] This was also highlighted in 2020 by the Independent Medicines and Medical Devices Safety (IMMDS) Review. Chaired by Baroness Julia Cumberlege, this looked at the harmful side effects of medicines and medical devices and how to respond to them more quickly and effectively in the future. It stated that: “We have found that the healthcare system – in which I include the NHS, private providers, the regulators and professional bodies, pharmaceutical and device manufacturers, and policymakers – is disjointed, siloed, unresponsive and defensive. It does not adequately recognise that patients are its raison d’etre. It has failed to listen to their concerns and when, belatedly, it has decided to act it has too often moved glacially.”[5] Again this was raised last year by the Parliamentary and Health Service Ombudsman. In their report, Broken trust: making patient safety more than just a promise, they stated that: “… political leaders have created a confusing landscape of organisations, often in knee-jerk rection to patient safety crisis points. HSIB, the Patient Safety Commissioner, PHSO, NHS England, NHS Resolution and more than a dozen different health and care regulators all play important roles in patient safety. But there are significant overlaps in functions, which create uncertainty about who is responsible for what. This means patient safety voice and leadership are fractured. This is not due to a lack of dedication and professionalism from those tasked with championing patient safety. The problem is structural.”[6] Patient perspective An overly complex system of regulation and oversight that cannot tackle underlying patient safety problems ultimately has a very real human cost. The persistence of avoidable harm, and every avoidable death and disability that accompanies this, is an unnecessary tragedy for patients, families and healthcare professionals. At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. We identify this as one of our six foundations of safer care in our report, A Blueprint for Action.[7] This is also one of the seven strategic objectives in the WHO Global Patient Safety Action Plan, which states that: “Patients, families and other informal caregivers bring insights from their experiences of care that cannot be substituted or replicated by clinicians, managers or researchers. This is especially so for those who have suffered harm.”[8] We would therefore stress the importance that this new review must feature a clear commitment to including and involving patients as part of the process. This should not be a top-down exercise without patient and public input. Safety culture We believe that we need a transformation in the health and care system’s approach to patient safety. Fundamental to this is patient safety not being seen as another priority, which in practice will be weighed (and inevitably traded-off) against other priorities, but as a core purpose of health and care. This will require a cultural shift in health and care in the UK. There remains a significant gap between what organisation leaders say about creating a patient safety culture in the NHS and what is done in practice. We see plentiful evidence of this in inquiries into unsafe care, whistleblower testimonies and staff survey results. This was an issue we examined in greater detail earlier this year in our report, We are not getting safer: Patient Safety and the NHS staff survey results.[9] In this context, we believe it would be beneficial if the review also considers the role of national leadership organisations in actively contributing and creating a just and fair culture in health and care. Safety Management System There is a growing debate in patient safety about the possible benefits that healthcare may gain from moving towards a Safety Management System (SMS) approach. SMSs are an organised approach to managing safety which are widely used in different industries. An SMS approach is used to: help enable proactive assessments of risks specify how risks should be managed set clear lines of accountability and responsibility in addressing risks. In considering the application of SMSs to UK healthcare, HSSIB in October 2023 published a report, Safety management system: an introduction for healthcare.[10] This identified the requirements for effective SMSs, how these are used in other safety critical industries and considers the potential of application of this approach in healthcare. A country-wide SMS would have the potential to provide a more structured and joined up approach to patient safety strategies, involving all the national bodies. Patient Safety Learning believes that integral to this is a standards-based framework to ensure safe, quality patient care is consistently delivered.[11] A patient safety standards framework helps organisations understand ‘what good looks like’ for patient safety, understand where more action is needed for improvement, with clearly defined safety aims and goals. Such a framework will enable organisations and regulators to demonstrate a risk-based approach to patient safety and evidence achievement, can provide assurance that patient safety sits at the organisation’s core, improves performance through increased effectiveness, and enables patients and families, staff, funders and communities to identify and differentiate good safety providers. This is an issue we believe requires serious consideration and we look forward to contributing as part of our submission to this review. References Department of Health and Social Car. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. Department of Health and Social Care. Independent report: Review into the operational effectiveness of the Care Quality Commission, 15 October 2024. Patent Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. CQC. Opening the door to change: NHS safety culture and the need for transformation, December 2018. The IMMDS Review. First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020. PHSO. Broken trust: making patient safety more than just a promise, 29 June 2023. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. WHO. Global Patient Safety Action Plan 2021-2030, 3 August 2021. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024. Health Services Safety Investigations Body. Safety management systems: an introduction for healthcare, 18 October 2024. Patient Safety Learning. Standards: What Good Looks Like, Last accessed 15 October 2024.

Patient Safety Partners (PSPs) are being recruited by NHS organisations across England as part of NHS England’s Framework for involving patients in patient safety. PSPs can be patients, relatives, carers or other members of the public who want to support and contribute to a healthcare organisation’s governance and management processes for patient safety.  In this blog, Chris Wardley, PSP at a large NHS hospital trust, introduces the Patient Safety Partners Network (PSPN). Chris describes his own experience of starting as a PSP, talks about the large scope of the role and highlights the unique opportunity to influence how an organisation approaches patient safety. He also invites PSPs to join the new network, talking about how it is already helping PSPs in England share learning as they shape their new roles. The Patient Safety Partner role introduced by NHS England is new and aims to take the involvement of patients, families and carers in how healthcare organisations are run to a different level. NHS England states that having a PSP “requires power sharing, a commitment to openness and transparency between staff and patients, as well as good leadership; it must not be tokenistic.”[1] The invitation to apply for the PSP role at our large hospital trust said, “this is a new and evolving role designed to shape the future of patient safety in our Trust and across the UK.” When we applied for the role, neither my fellow PSP nor I appreciated the implications of these bold and grand words. PSPs bring with them a wide range of backgrounds and experience, but most importantly, they are there to offer a patient’s perspective. In our careers, both of us held roles leading innovation for change. My fellow PSP trained as a nurse in the same Trust and was a senior nurse in others before moving into nursing education. I am a chartered engineer and former senior manager in the construction industry. Both of us had also spent several years promoting the patient, family and carer voice in a county-wide role. When we started as PSPs earlier this year, neither of us expected to have any influence for a while. But after a few months, we started to make welcomed prompts and suggestions. Now after six months, this is progressing rather faster, and we are excited that we have a small but important part to play in improving patient safety in our Trust. Why do Patient Safety Partners need a network? Some PSPs are supported by local networks—which might be informal arrangements between local trusts or organised by Integrated Care Boards—but very many aren’t. Organisations are recruiting to these new roles in many ways, seeking a wide range of experiences and expecting very different levels of engagement and influence from the PSPs they engage. The PSPs who are part of the Patient Safety Management Network (PSMN) suggested that an informal, peer support and learning community specifically for PSPs would be valuable. We were therefore delighted that Patient Safety Learning agreed to convene a discussion forum and following this, support a dedicated network. The Patient Safety Partners Network (PSPN) is only a few months old but already has over 70 members. It has held three virtual meetings, focusing on topics of interest to PSPs: communication and variation in PSP roles between trusts. Since we started as PSPs, we have both found the network a great resource for sharing and learning from others both in the same role and outside it. Having the opportunity to connect with PSPs working in different settings gives us the opportunity to hear new perspectives and support each other. At the meetings, we talk about how our role is playing out in real life, what our expectations and issues are, and how we are each getting involved in improving patient safety. It’s a unique opportunity to learn from each other and understand how other organisations are dealing with patient safety issues and big governance changes such as the roll out of the Patient Safety Incident Response Framework (PSIRF). [2] The conversations we’ve had have been very helpful. We’re beginning to understand the variation in roles in terms of how PSPs are engaged, their level of involvement in organisational processes and governance, and what they are being asked to do practically. The network is currently running a survey for PSPs to help establish how they are operating across England. As they become established, PSPs are taking a range of approaches—some are beginning by engaging with patients and front-line staff, while others are finding a place on senior level committees. At our Trust, my fellow PSP and I have focused on using our different experiences and strengths. Wherever you are focusing your time, being a member of the PSPN can help you gain the information and confidence to connect with the people in the engine room of your Trust, where you can have a real influence on making improvements for patients. Commitment The PSPN meets online each month on a Tuesday—we alternate meetings between daytime and early evening to fit the availability of different members. Several of our members take turns to chair the meetings and all PSPs are welcome. Our meetings last an hour, and the discussion is always based around topics raised by members. We would love to hear your views and experience at the meetings, but there is no pressure to contribute if you prefer to just watch and listen. You can also use the chat function in Teams to ask questions and suggest topics during the meeting. Someone takes notes at each meeting so that those who are unable to attend can catch up, but these are only shared on the private PSPN area of the hub, and all comments are non-attributable. The PSP network meetings are safe spaces amongst colleagues. Membership The network is open to Patient Safety Partners working with NHS organisations in England. It is hosted on the Patient Safety Learning hub and you can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Partners Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected] to apply to join the PSPN. Other patient safety networks supported by the hub Find out more about the growing number of informal peer support networks hosted and supported by Patient Safety Learning. The networks provide a forum for people involved in patient safety to meet up, share ideas and initiatives and learn from others. Related reading Patient Safety Partners - A workshop at Kingston Hospital Reflections on PSIRF, patient engagement and why we investigate: a recent discussion at the Patient Safety Management Network Top picks: PSIRF insights and opinions Top picks: PSIRF tools, templates and examples References 1 Framework for involving patients in patient safety. NHS England and NHS Improvement, 29 June 2021 2 Patient Safety Incident Response Framework. NHS England, 16 August 2022 3 NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS England and NHS Improvement, 2 July 2019