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Found 415 results
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Content ArticleIn edition 14 of her newsletter, Judy Walker reflects on the Patient Safety Incident Response Framework and the learning tools two years after her first survey to understand what has changed and whether organisations have moved from implementation to optimisation, how effectively After Action Reviews (AAR) and other tools are improving safety and outcomes, and how well they are now embedded in governance and organisational learning. She invites readers to complete her new survey: Survey on Learning Response Tools and After Action Review (AAR) 2026
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Content ArticleThe Learn from patient safety events (LFPSE) service is a national NHS system set up by the National Patient Safety Team at NHS England, it is free to use and is available online as a web portal, to record information about patient safety events and support the improvement of safety across all care settings. NHS Somerset has produced an information sheet for primary care.
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Content ArticleHow are you really using Patient Safety Incident Response Framework (PSIRF) learning response tools and After Action Review (AAR) in practice? In 2024, Judy Walker Associates Ltd captured a snapshot of early adoption. Now, Judy is revisiting that picture to understand what’s changed, what’s working well and where further support is needed. If you’re working in patient safety, governance or service improvement, she would really value your insight. The survey takes just 10 minutes to complete and the results will be shared widely. As a thank you, participants can opt in to a Prize draw for a FREE PLACE (for you or a colleague) at one of the AAR Conductor Professional Development Days that Judy Walker will be running in October. Your experience will help shape future support and strengthen learning across the system. Take part here
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Content ArticleThe Patient Safety Incident Response Framework became mandatory for all health services contracted under the NHS Standard Contract, including NHS-funded care delivered by independent healthcare providers, in April 2024. It replaced the Serious Incident (SI) framework. The change in approach to investigations under PSIRF has resulted in some practical challenges to the way in which information and organisational learning evidence is presented to the coroner for inquests. Chaired by Amelia Newbold, Risk Management Lead, this Shared Insights session discussed how the PSIRF and coronial processes can work more effectively together to ensure that coroners receive the information they need for inquests while preserving PSIRF's core principle of fostering a learning culture within healthcare. Bringing together perspectives from across the system, we explored some of the key challenges and, importantly, shared positive and practical examples of how a collaborative approach across both learning and coronial processes can ensure that relevant information is shared effectively.
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Content ArticleMaking Families Count have compiled this information for families and friends of people who have been harmed when something has gone wrong in NHS provided or funded healthcare in England. This may mean something unexpected happened in care, or someone has been harmed. This is called a safety event by the NHS. You will find information about the NHS investigation process and a downloadable template document for a family to use (if you wish) to help to organise your thoughts and feedback, and to provide information to assist the investigation.
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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. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and the role of human factors within the new Patient Safety Incident Response Framework (PSIRF). Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care and safety. Understand the role of human factors in improving culture and delivering psychological safety. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register We are pleased to offer hub members a free place using the code HCUK00HFPSL
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Content ArticleIn alignment with the implementation of the Patient Safety Incident Response Framework (PSIRF), East London NHS Foundation Trust conducted a comprehensive five-year analysis of reported incidents. This review analyses 411 completed investigations of serious incidents (SIs) and patient safety incidents (PSIIs) reported in the Trust from 2020 to July 2024. With patient safety as a top priority, this analysis examines whether key issues identified in these investigations have shown recurring patterns over time.
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Content ArticleQualitative research methods explore and provide deep contextual understanding of real world issues, including people’s beliefs, perspectives, and experiences. Whether through analysis of interviews, focus groups, structured observation, or multimedia data, qualitative methods offer unique insights in applied health services research that other approaches cannot deliver. However, many clinicians and researchers hesitate to use these methods, or might not use them effectively, which can leave relevant areas of inquiry inadequately explored. Thematic analysis is one of the most common and flexible methods to examine qualitative data collected in health services research. This article offers practical thematic analysis as a step-by-step approach to qualitative analysis for health services researchers, with a focus on accessibility for patients, care partners, clinicians, and others new to thematic analysis. Along with detailed instructions covering three steps of reading, coding, and theming, the article includes additional novel and practical guidance on how to draft effective codes, conduct a thematic analysis session, and develop meaningful themes. This approach aims to improve consistency and rigor in thematic analysis, while also making this method more accessible for multidisciplinary research teams.
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EventuntilThis practical and engaging two-day course will explore how the SEIPS (Systems Engineering Initiative for Patient Safety) framework can be applied within health and care investigation and design to support safer, more effective systems and services. Whether you are involved in patient safety, investigation, quality improvement, service design or systems thinking, this course will provide valuable insight and practical tools to apply in your organisation. SEIPS in Health and Care Investigation and Design is an interactive two-day face-to-face course designed to introduce participants to practical systems-based investigation and design using the Systems Engineering Initiative for Patient Safety framework (SEIPS). Through collaborative workshops and realistic scenarios, learners will work alongside others to explore and analyse real-world incidents and system challenges commonly encountered across health and care settings. Participants will develop practical skills in identifying how people, environments, technologies, organisational factors, and workflows interact to influence safety, quality, and care outcomes. Delivered in a supportive learning environment, the course is facilitated by experienced faculty leading work across systems thinking, human factors, and safety investigation. Learners will have opportunities to discuss ideas, test approaches, and build confidence applying SEIPS methods through guided simulation and group-based activities. By the end of the course, participants will have developed a structured approach to investigating complex system issues and designing practical, system-focused improvements for health and care services. To find out more or book your place, please email: [email protected]
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework (SIF) and became the mandatory patient safety incident response framework for services provided under the NHS Standard Contract in England in Autumn 2023. With a move away from Root Cause Analysis (RCA) towards a systems-based approach, PSIRF is designed to enable timely and proportionate responses to patient safety incidents, using varied evidence-based methods to generate impactful learning, whilst also fostering openness and a culture of continuous improvement. This article from Browne Jacobson, a law firm, reviews nine published Prevention of Future Death (PFD) reports referencing PSIRF, identifies the key themes arising and considers their practical implications for healthcare providers preparing for inquests. ‘PSIRF’ themes from PFD reports: Inadequate incident reporting. Failure to appropriately ‘investigate’. Poor quality of learning response/investigation. Shortcomings in record-keeping and disclosure of documentation for inquests. Lack of evidence of organisational learning.
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Content ArticleEdition 12 of the After Action Review (AAR) newsletter reflects on how After Action Reviews (AARs) are being used in the Patient Safety Incident Review Framework (PSIRF) and argues for a shift away from overly detailed, 'historian-style' reporting towards concise, improvement‑focused summaries that clearly capture learning and agreed actions. Drawing on recent AAR Conductor training, it explores why staff may struggle to let go of exhaustive documentation—linking this to professional identity, perfectionism and misdirected agency—and emphasises that people, not reports, drive safety improvement.
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After Action Review Masterclass
Patient Safety Learning posted an event in Community Calendar
An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR Register hub members receive 20% discount. Email [email protected] for discount code. -
Content ArticleThis guidance is for users of the new Learn from Patient Safety Events (LFPSE) service, to provide context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content ArticleThe Health Services Safety Investigations Body (HSSIB) engaged with a wide range of stakeholders, including clinicians and national leads, to learn more about the issues surrounding learning from patient safety events in mental health settings and to identify areas where an investigation could focus to help improve patient safety. Although suicide has been the focus of extensive national work, it has persisted as a safety risk. The themes from incidents and complaints have remained the same over time. Evidence from the intelligence gathered suggests that greater insight into the challenges faced at an organisational level when a service user has attempted suicide, or taken their life, would be helpful. To support NHS organisations and local investigation staff, HSSIB identified an opportunity to model approaches to patient safety incidents investigations (PSIIs) under the NHS Patient Safety Incident Response Framework (PSIRF). Stakeholders told HSSIB that this would help to increase local learning and provide examples of how PSIRF tools can be used to improve investigations. HSSIB has also used this opportunity to identify learning that may help to improve how PSIRF can support staff in carrying out incident investigations. This investigation has used the PSII report template and PSIRF tools to investigate an attempted suicide in the community mental health setting. Findings and areas for improvement are listed for the organisations that were involved in this incident. However, the learning may be relevant to other organisations. Summary of key findings The investigation found that: The Service User’s attempt to end his life was not expected by the mental health staff supporting him. The change to his medication meant it was a potentially vulnerable time for the Service User's mental health. This was despite him having a safety plan for how to seek help if he felt overwhelmed and planned monitoring check-ins in line with local procedure. The Service User’s case was complex and challenging; his mental ill-health, drug and alcohol use are likely to have impacted on his ability to reason and make informed decisions. Therefore, sharing of information across and between healthcare services was important to facilitate personalised care planning. Limited sharing of, and lack of ready access to, information about the Service User and his past mental health history impacted on the CMHS’s ability to provide effective and timely care. The Service User needed a tailored approach with reasonable adjustments to maximise his engagement with mental health services; there was a delay in his needs being identified and acted on. There was limited understanding and awareness by some staff of whether mental health medication can be offered to service users with mental health issues and concurrent alcohol use. Staff worked in a service that was overstretched and they had to make decisions about managing service user needs, service demand, and risk and safety, within limited resources. The demand for CMHT services exceeded the available capacity, impacting both service users and staff. Staff did not have the dedicated time and space to process and deal with distress they encountered as part of their daily work caused by incidents of patient harm. There are challenges to delivering the national ambition to provide a community focused model of care, many of which the mental health trust has limited or no control over. Summary of areas for improvement The investigation identified four areas of improvement which the mental health trust could develop safety actions to address. Area of improvement 1: Making information about service users easily available and accessible across providers to support effective initial engagement and decision making. Area of improvement 2: Early exploration of adjustments that individual service users might need to engage in the triage and referral processes. Area of improvement 3: Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol. Area of improvement 4: Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
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Content ArticleStef Cormack, Patient Safety Specialist at Sandwell and West Birmingham Hospital NHS Trust, recently presented at the Patient Safety Management Network meeting on the work she has been doing on the Patient Safety Incident Response Framework (PSIRF) and with coroners. Attached is the template the Trust uses to supplement the evidence the Trust provides to the Coroner for the purposes of the Inquest investigation, and to summarise the investigations, findings, conclusions, learning points and actions, which form the Trust’s response to the relevant patient safety incident(s) under PSIRF. Steph is happy for other organisations to adapt and use. Patient Safety Management Network You can apply to join the Patient Safety Management Network by signing up to the hub today. When you complete the registration form you’ll see a section called ‘Join a private group’, please tick the box by the relevant Network. If you are already a member of the hub, please email [email protected].
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Content ArticleFamilies affected by a loved one’s death due to problems in healthcare often want what happened to be understood, acknowledged and for real change to occur. In 2017, the NHS in England introduced the Learning from Deaths programme. Its aim was simple: to ensure that when patients die, especially where problems in care may have contributed, organisations learn and improve. But nearly a decade on, an important question remains: Is the system truly learning and are families genuinely part of that process? Drawing on her research evaluating this national programme, Dr Zoe Brummell shares what she found and what it means for families.
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Content Article
Chris Elston, a patient safety education lead, shares his journey on how he learnt and used thematic analysis in his trust, which led to him designing a lesson for his colleagues and then wider teaching outside his organisation. For many years I have thought that we could make a bigger impact on patient safety if we could examine low harm events or near misses in greater detail. Historically, they have often been left to local areas to investigate and close them. With all the time pressures and demands on them, it is hardly surprising that many get a superficial look rather than an examination. Thematic analysis allows us to do a good delve into these areas and so I sought to complete two analyses: one on falls and the other on pressure ulcers. I thought that they lent themselves to this style of analysis. I mean how hard could it be, a week or two and the analysis would be done. Simple, isn’t it? Well, I can only say how wrong I was. The first analysis took about three months to complete, the second one, a little longer. At this point, I will be honest—despite the raft of available data sources, I only used the adverse event reports (AERs). I think it may have been longer if other data sources had been used. I was pleased with the result; it showed lots of useful information that could be shared with the steering groups and individual areas to help inform their practice. Soon after this, the Patient Safety Incident Response Framework (PSIRF) was introduced and the use of thematic analysis was one of the tools that PSIRF recommended. This meant that a greater understanding of thematic analysis was required. So, after a brief hiatus, I started to research a little more about thematic analysis and its application and found there was much more to thematic analysis than I had first realised. Designing a lesson I wanted to design a thematic analysis lesson for my trust. What did people need to know before they could use it? I was no expert and I needed to learn before I attempted to teach it, so what did I need to know? My initials thought were: How do you define thematic analysis? What types are there? When could it be used? What are the advantages and disadvantages of thematic analysis? Where can we get data from? How can we code/map the data into themes? So began a journey; what should have been a short journey but has taken a few twists along the way. I developed a 2-hour lesson with what I considered to be the essentials of thematic analysis. This was then delivered in my trust, which led to some changes in our processes. This meant that thematic analysis became much more of a featured learning response. Following this, I was then asked to assist one of our wards on a project and we started with a … thematic analysis. I never dreamed I would be doing something like this. Expanding the training After a year or so, I answered a question posed on NHS Futures about thematic analysis training. I replied that I had a lesson and was willing to meet and discuss with people. I did not expect the response that I got. People from all sorts of healthcare organisations, within the NHS and outside of it, wanted to discuss thematic analysis. I was shocked and stunned at the response. I have often said, if we do not collaborate then we will never drive patient safety forwards at a great enough pace to safeguard patients and staff. So I elected to share some of my teaching. My trust offered to host some meetings, we discussed the training I could provide and what I felt comfortable sharing. There was just over 100 people interested in attending the meetings. As the time got closer, I became increasingly nervous. The imposter syndrome hit hard—I was going to be found out as a fraud and not nearly as switched on as many appeared to think. Was this such a clever idea? Conclusion We are now about 6 weeks from the last meeting and I can breathe a sigh of relief. Everything went ahead in a positive manner. Feedback has been good, although I think I could have made better use of technology and that is a lesson learnt for the future. Many in healthcare are willing to make the necessary changes but they want support in this; coaching and mentoring will be critical to delivering PSIRF. This is just one step on that path (motorway, could be a better analogy!). The experience has shown how powerful collaboration is. Further reading on the hub: Patient Safety: Emerging Applications of Safety Science "The greatest part of this adventure has been the sharing of information." Conducting a systems review of pressure ulcers in the intensive care unit -
Event
Understanding the Patient Safety Framework
Patient Safety Learning posted an event in Community Calendar
untilHow the Patient Safety Framework and related investigations should work when serious incidents happen Join Making Families Count for a new series of lunchtime online seminars for families, carers, and health professionals. These free one-hour sessions bring together expert speakers with family carers to explore key issues in mental health care, patient confidentiality, suicide bereavement, and patient safety. Each event will include the opportunity to submit questions in advance. Whether you are supporting a loved one, working in health services, or seeking to better understand these issues, these sessions aim to provide practical insight, clearer understanding, and greater confidence. Led by: Ashley Windebank-Brooks, Head of Patient Safety at North Bristol NHS Trust Respondent: [Name to be confirmed] About this session This session will explain how the Patient Safety Framework and related investigations should work when serious incidents happen. Topics will include: What patient safety investigations are for. What families should be entitled to expect. What good practice looks like. How learning and accountability should be handled. A valuable session for anyone wanting to better understand how safety investigations should support learning, transparency, and improvement. Register -
EventuntilThe change in approach to investigations under PSIRF has resulted in some practical challenges to the way in which information and organisational learning evidence is presented to the coroner for inquests. Join Browne Jacobson for a discussion on how the PSIRF and coronial processes can work more effectively together to ensure that coroners receive the information they need for inquests while preserving PSIRF’s core principle of fostering a learning culture within healthcare. Bringing together perspectives from across the system, we will explore some of the key challenges and, importantly, share positive and practical examples of how a collaborative approach across both learning and coronial processes can ensure that relevant information is shared effectively. Chaired by Amelia Newbold, Risk Management Lead and Katie Viggers, Professional Development Lawyer in the Inquest and Advisory Team, we are delighted to be joined by an experienced panel who will share their experiences and insights: Mr Graeme Irvine, HM Senior Coroner for East London. Lauren Mosley, Head of Patient Safety Incident Response Policy, NHS England. Stef Cormack, Head of Patient Safety at Sandwell and West Birmingham NHS Trust. Conor Lees, Head of Legal Services at Sandwell and West Birmingham NHS Trust. Delegates will have opportunities to put questions to the panel, gain their perspectives on specific issues, and share ideas and solutions with organisations across the health sector. Register
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Content ArticleOn 25 February 2026, healthcare leaders and stakeholders gathered in London for the Patient Safety Forum, organised by Public Policy Projects (PPP) in partnership with Patient Safety Learning. Panellists at this event investigated multifaceted impacts patient safety measures are having on wider system operations. From avoiding duplicated processes and failure demand, to cross-disciplinary learning and efficiency gains, this blog summarises discussions from two panels which highlighted the Patient Safety Incident Response Framework and productivity as focuses for a reforming healthcare system. Read the full article from PPP via the link below.
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Content ArticleThis report looks at the past three years since the introduction of the Patient Safety Incident Response Framework (PSIRF) and its application in the independent sector. It explains how the Independent Healthcare Providers Network has been supporting its members to implement PSIRF and outlines key learnings that have emerged from this.
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Event
Effectively embedding medication safety into PSIRF
Mark Hughes posted an event in Community Calendar
untilThis interactive session, hosted by the NHS Specialist Pharmacy Service, forms part of the ‘Medication Safety Across the System’ (MSATS) series aimed at healthcare professionals, working in any sector with a role or passion for medication safety and/or involved in medicines use. Speakers share their experience of using the Patient Safety Incident Response Framework (PSIRF) and learning response tools to support medication safety improvements. They aim to inspire and equip translation and replication across systems. What will be covered: The impact that embedding medication safety within PSIRF plans can have on the safer use of medicines. Current barriers and challenges to embedding medication safety in PSIRF. The importance of ensuring that the patient and carer perspective is central to PSIRF implementation. Shared exemplar practices where medication safety has been effectively included within PSIRF plans to inform local adaptation. Opportunities to network with peers to inform the development of appropriate local and system wide actions to embed medication safety in PSIRF plans. Register here. -
Content ArticleOn 25 February, the Patient Safety Forum took place, organised by Public Policy Projects (PPP) in partnership with Patient Safety Learning. In this blog, Joanna Lloyd, Partner at Bevan Brittan, took part in a session on the Patient Safety Incidence Response Framework (PSIRF). In this blog (attached), Joanna reflects on the day and provides a list of key take-aways from the PSIRF session.
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EventThis 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] hub members can register for the reduced rate of only £195 +vat. Please quote code HCUK195psl.
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EventThis course is aimed at those who wish to lead and conduct thematic reviews and those who are part of an themed review team. Through national updates and practical case studies, the conference will explore how thematic reviews can identify recurring safety issues and drive meaningful improvements in patient care. Sessions will provide insights into conducting system-based reviews, analysing qualitative data, and developing actionable safety recommendations. The conference will also focus on building confidence and competence in thematic review processes to support a proactive, learning-centred approach to patient safety. hub members can receive a 20% discount with code hcuk20PSL. If you are a member of the Patient Safety Management Network or Patient Safety Education Network you can book for only £195 +vat with code HCUK195psl. Register here.
