Search the hub

Judy Walker Associates are hosting a training day in London on 2 October for individuals, rather than groups to attend. We’ve been receiving requests from people in primary care, independent providers and previous clients for individuals to access our professional development for AAR Conductors, so are happy to accommodate. Participants will get live AAR practice and feedback, learn about the Five Switches of advanced facilitation and understand how to involve patients and families successfully in AARs. Please get in touch and we can send you a flyer [email protected]

This Patient Safety Incident Response Framework (PSIRF) table was produced, following lunch and learns around the PSIRF tools with site teams, to provide some direction.  It is based on Circle Health Group's Patient Safety Incident Response Plan (PSIRP). PSIRG is our oversight group for significant incidents. The table lists the PSIRF tools readily used at Circle Health Group: as a standalone tool as an element of an investigation example incidents must haves—to optimise tool usage.

This month marks a significant milestone for the Patient Safety Management Network (PSMN) as we celebrate its fourth birthday. Launched in June 2021 with just four members on its inaugural call, the Network has grown exponentially to now include almost 2000 members—a powerful testament to the need for, and value of, a connected, collaborative community focused on patient safety. PSMN founder Claire Cox reflects on its achievements, the impact it is having and how it is evolving.  Over the past 4 years, we have hosted 190 meetings, each one an opportunity for members to learn, reflect and share ideas. From January to June 2025 alone, an average of 107 people joined each session, highlighting the continued appetite for learning and improvement among safety leaders across the UK. The Network draws together a unique and diverse membership. It includes individuals involved in patient safety from inside the NHS, outside the NHS, patient safety partners, regulators, commissioners and those on the peripheries, such as academics. We even have a contingent of safety professionals from the veterinary sector joining us! This breadth allows the PSMN to cross organisational, professional and geographical boundaries, ensuring that a wide range of perspectives are shared and valued. At its heart, the network is committed to fostering a psychologically safe space where everyone can learn, contribute and feel supported. A shift towards collective wisdom While we have welcomed 75 external speakers since our inception, the past year has marked a meaningful shift in how we share knowledge. We are moving away from a traditional model of learning from outside experts to one where our Network members are the experts. This shift recognises the depth of experience and insight within the Network and underscores our commitment to shared learning. As Patient Safety Learning noted, the power of Networks lies in their ability to connect people with a common purpose and enable the co-creation of new knowledge.[1] The PSMN has become just that: a space where members bring real-time challenges, innovative practices and lived experiences to the table, enriching the dialogue and pushing the boundaries of what is possible for patient safety. Building a culture of openness and trust From the outset, the ethos of the PSMN has been one of openness, humility and continuous improvement. As we noted in previous blogs,[2] the network has created a psychologically safe environment where members can speak candidly about what is and isn’t working. This culture has not only fostered trust but has also accelerated learning and adaptation across organisations. One of our highlight meetings in the past year focused on the Duty of Candour. These two sessions led to a valuable collaboration with NHS England, NHS Resolution and the Care Quality Commission, resulting in the development of a Frequently Asked Questions resource.[3] This resource was directly shaped by the questions and discussions raised during our Network meetings, demonstrating the tangible impact of shared learning in action. Collaboration and shared learning Last September, we hosted a highly successful Patient Safety Learning Symposium, bringing together professionals and experts from across our Network. The event provided a dynamic platform for collaboration, with participants sharing insights and best practices to improve patient safety across care settings. A key highlight was the depth of expertise within our Network, showcased through interactive workshops on ACCIMAP and SEIPS. These sessions enabled delegates to explore systems-based approaches to understanding and preventing harm, with practical applications for analysing incidents and designing safer processes. Capturing our learning in print A major success for the Network has been the publication of our first book, Patient Safety: Emerging Applications of Safety Science.[4] This collaborative work showcases a series of case studies contributed by our own members, reflecting the real-world challenges and innovative approaches discussed in the Network. It stands as a lasting record of the depth and breadth of expertise within the community and has been met with widespread acclaim for its practical insights and relevance. Building on this success, we are now in the process of writing the second book in the series. This new volume will further explore emerging themes and continue to amplify the voices of those working at the forefront of patient safety. Impact of the Network The Network is proud to have contributed to the working group informing the Health Services Safety Investigations Body (HSSIB) report on fatigue.[5] Recognising fatigue as a serious risk to both patient and staff safety, our involvement helped ensure the report reflects real-world challenges across healthcare. By sharing frontline insights and data, we helped highlight the systemic factors behind fatigue and the need for a national strategy. In a further positive step, we are delighted to welcome a student from University College London (UCL) who will evaluate the Network’s impact on patient safety and wider system function. This collaboration will offer valuable insight into our progress and help guide our future work. Looking ahead As we celebrate this milestone, we also look forward. The next phase of the PSMN will build on the foundations we have laid together. We will continue to harness the expertise within our membership, support each other through shared challenges and champion the changes needed to deliver safer care. To every member who has contributed to the network over the past 4 years: thank you! Your willingness to share, support and learn from one another is what makes the PSMN not just a network, but a movement. References Patient Safety Learning. Patient safety and the power of collaboration (a blog by Patient Safety Learning). Patient Safety Learning, 9 December 2024. Cox C. “We’ve created an incredible pool of talented safety people who are up for collaboration.” Marking three years of the Patient Safety Management Network. Patient Safety Learning, 2023. Patient Safety Learning. Patient Safety Management Network: Strengthening understanding of Duty of Candour through collaboration. Patient Safety Learning, 2025. Cox C, Hughes H, Nicholls J. Patient Safety: Emerging Applications of Safety Science. Class Publishing: Bridgewater, UK; 2024. HSSIB. Investigation report. The impact of staff fatigue on patient safety.  Health Services Safety Investigations Body, April 2025. How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools Who should attend: Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Facilitator: Jo Perruzza is a former mental health nurse and has been a clinician, a clinical leader and a senior manager in mental health provider organisations. With a passion for patient safety and an expert in psychological safety she brings experience of leading internal and external investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

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. 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 [email protected] for discount code.

An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). The morning will be a hands on interactive masterclass which will develop your skills in conducting an AAR using simulated case study AAR examples and facilitated discussion. The afternoon will focus on case study sessions from experts who are using AAR in practice. Topics will include AAR under the Patient Safety Incident Response Framework (PSIRF), walkthrough case studies of AAR in action, the role of human factors in AAR and delivering change. There will be an extended focus on informing and involving patients in AARs in line with national guidance “Many national reports clearly articulate the importance of engaging with patients, families, and staff appropriately after a patient safety incident and involving them in any subsequent investigation.” NHS England. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/after-action-reviews or email [email protected]. Follow the conference on X @HCUK_Clare #AfterActionReviews hub members receive a 20% discount. Email [email protected] for discount code.

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.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

The course will provide participants with an in-depth knowledge and understanding of how to not only comply with the duty of candour and the Patient Safety Incident Response Framework (PSIRF), but to do so in an emotionally intelligent way, with empathy and compassion for all involved. Practical guidance on complying with the regulations and guidance The “grey areas” and what people most often get wrong Using emotional intelligence to understand the difficult emotions experienced by patients/those closest to them and staff following patient safety incidents What empathy and compassion mean in practice Handling difficult and emotive conversations well Making a meaningful apology How Duty of Candour and PSIRF work alongside other policies and procedures including complaints; litigation; Martha’s Rule and the soon to be introduced “Hillsborough Law” How the new “Harmed Patient Pathway” can help you get it right 7 How to ensure communication moves beyond compliance and frameworks but remains emotionally intelligent and personal Register hub members receive a 20% discount. Email [email protected] for discount code.

This national conference looks at the practicalities of responding to patient safety incidents for learning and improvement under the Patient Safety Incident Response Framework (PSIRF). The conference will also update delegates on best practice in patient safety incident investigation and response systems and include an practical case study based overview of key tools and techniques that can be used to investigate incidents including under PSIRF including After Action Reviews, SEIPS and Thematic Reviews. There will be a focus on understanding your patient safety incident profile and managing and ensuring accountability for ongoing safety actions in response to recommendations for investigations. You will also receive a legal perspective on PSIRF and how PSIRF relates to the learning from deaths criteria, Medical Examiner and Coroner system. The conference will support you to compassionately involve those affected by patient safety incidents and challenge your pre existing lens to inspire cultural change with PSIRF and deliver improvement. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/serious-incident-investigation-patient-safety or email [email protected] hub members receive a 20% discount. Email [email protected] for discount code.

This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in their own safety, and patient involvement under the Patient Safety Incident Response Framework. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email [email protected] Follow the conference on X @HCUK_Clare #PatientPSP2025 hub members receive a 20% discount. Email [email protected] for discount code.

Swarm is one of the learning tools that can be used for the Patient Safety Incident Response Framework (PSIRF). A Swarm is designed to start as soon as possible after a patient safety incident occurs. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. In this Top picks, we’ve pulled together 8 hub resources on Swarm, including a number of templates organisations have shared with us. 1 NHS England: Swarm huddle This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done). 2 PSIRF templates - AAR, Swarm, Rapid Review These templates were developed by Liverpool Heart and Chest Hospital for use in After Action Review, Swarm and Rapid Review toolkit responses. 3 Swarm debrief guide (Epsom and St Helier Hospital) Epsom and St Helier Hospital have developed a Swarm guide and fictional example video, for use by those who wish to use the Swarm debrief learning response as part of their PSIRF work. 4 Swarm video (Epsom and St Helier Hospital) This Swarm fictional example video was developed by Epson and St Helier Hospital to demonstrate how you can carry out a Swarm debrief using the Swarm guide. 5 Four PSIRF learning response tools (iTS Leadership) In this article, Judy Walker compares the four tools that can be used for PSIRF, including Swarm, explaining what they are and their strengths and weaknesses. 6 Swarm: a quick and efficient response to patient safety incidents Two years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. This article in the Nursing Times describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust. 7 Yorkshire Ambulance Service: Swarm huddle tool This infographic from the Yorkshire Ambulance Service explains what Swarm is, when you would use it, who should be involved in it and who should lead it, and it's strengths and weaknesses. 8 SpaMedica: Swarm templates At a recent Patient Safety Management Network meeting, SpaMedica shared insights into their PSIRF journey, offering a unique perspective on how the independent sector implements PSIRF. They have shared their SWARM templates, including one for falls, and Swarm Charter with the hub. Share your SWARM resources If you have insights, tools or knowledge to share relating to SWARM why not comment below (you will need to be a member of the hub and sign in) or get in touch with us at [email protected]. At Patient Safety Learning we are also always keen to share good practice, challenges and training resources that could help support safe care more widely.