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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.

Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging?  More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way.  Frozen (or more importantly, in the words of Idina Menzel, "Let it go") Let it go! Let it go! Bureaucracy and burden in incident response. Let it go! When implementing PSIRF there is a temptation to create reporting structures around the PSIRF toolkit, which retain or introduce unnecessary bureaucracy. Why do you have to ‘let it go?’ Bureaucratic reporting structures around After Action Review (AAR) and SWARM huddles transform what are intended as empowering, free-choice and reflective team learning conversations into something they were never intended to be. "The process will be as follows, staff report the incident on the incident reporting system. Incidents will be screened by the central patient safety team. Those incidents meeting the ‘criteria’ for an After Action Review will then be scrutinised at the Patient Safety and Risk Group meeting – which will meet weekly. The Patient Safety and Risk Group have the decision-making authority. They will notify the reporter whether the incident warrants an After Action Review." If you are having conversations like this, it is time for a re-think. If your incident response oversight conversations are starting with, "What should have happened and what did the staff involved do that led to the incident?" you are not letting go of the old-style ‘shoulda, woulda, coulda’ counter-factual thinking model that dominated our thinking under SIF. Our conversations should be starting with, "Who are ‘those affected’? How are we supporting them? Have those affected shared their views on how we might best support them? How can we meet their individual needs, to ensure we provide personalised support for everyone?" And, in relation to specific patient safety incidents, "What does our plan tell us about the potential for learning and improvement? Is the incident either a national or local safety priority? Is it a newly emerging incident which we were not aware of when we wrote our PSIRP? What (if any) ongoing improvement work is underway? What would a proportionate response look like? Given what we know so far, and what is set out in our plan, what tools in the PSIRF toolkit should we apply to learn from this incident?" Don’t be Frozen. Abolish unnecessary bureaucratic structures and reporting. Empower and engage staff to use the proportionate tools in the PSIRF toolkit. And that leads us onto our next movie… Apollo 13: "Houston – we have a problem!" Apollo 13 was the seventh crewed mission in the Apollo space programme and the third meant to land on the Moon. The craft was launched from the Kennedy Space Center on 11 April 1970, but the lunar landing was aborted after an oxygen tank in the service module failed two days into the mission. For two days, Mission Control in Houston and the crew improvised new procedures so it could support three men with sufficient oxygen to survive for four days. Starring Tom Hanks as Jim Lovell, the commander of Apollo 13, the movie tells the story of the mission. Jim Lovell coined the term, "successful failure". He states that, to solve any problem, organisations need to ensure teams have leaders who foster good teamwork, empowering team members to use their initiative. Leaders also need to recognise that solving a problem starts with digesting what the problem is. Leaders need to give team members space to recognise what has happened, offer a supportive steer, and give them the time and space to think creatively. Leaders in oversight roles need to adopt this approach to support organisations and enable their PSIRF transition to become a success. When using the tools in the PSIRF toolkit, remember testing and adapting them is part of your PSIRF implementation journey. Adopt the quality improvement mantra, "go where the will is". If you discover a PSIRF pioneer or enthusiast who is keen to use one of the PSIRF tools, empower them to do so. And that theme of empowerment and going where the will is, segways nicely into our next movie... Fences: Breaking down silos will enhance safety improvements The movie Fences, starring Viola Davies and Denzel Washington, includes the quote: "Some people build fences to keep people out and other people build fences to keep people in." PSIRF is a significant change in policy, process and behaviour. It’s an organisational development intervention that should have the full support of leaders to create new ways of working that will support organisational learning, action and cultural change. Some (not all) healthcare organisations have traditionally been organised so there are separate teams or functions who lead on patient safety, quality improvement, AAR/debriefing, human factors science, etc. Collegiality and collaboration between patient safety, human factors, quality improvement and AAR/debriefing experts is essential for successfully implementing the PSIRF toolkit. Quality improvement empowers front-line staff to innovate and lead the change: the testing, adapting, adopting, or abandoning principle and much more. Human factors scientists are vital for understanding ‘work as done’ and for identifying strong safety actions and systems redesign that is user-centred. Human factors scientists can also provide insights into user-centred, PSIRF tool template design and can support testing the usability of PSIRF tool templates. By PSIRF tool template design, we mean how we design templates and pro formas to capture what we have learnt when applying tools in the toolkit. We talk more about this later in the blog… AAR/debriefing experts have the skill set to create a psychological safe space for reflective learning. They will also provide sage advice that tools like AAR, if implemented in their truest sense, should be free-choice learning conversations, where creating a psychological safe space is essential. In short, combining collective wisdom is the way forward when implementing the PSIRF toolkit and making decisions about how to report what is learnt. Forrest Gump: "My Mama said, ‘Life was like a box of chocolates: You never know what you are going to get'". Complex, highly adaptive systems like healthcare comprise multiple subsystems that interact in a myriad of ways. This in turn means system performance can be unpredictable. The Forrest Gump quote, "My Mama said, Life was like a box of chocolates: You never know what you are going to get," captures one of the challenges of improving patient safety in healthcare. We cannot predict what type of patient safety incident will happen next, or when and where it will happen (despite often seeming alarmingly obvious in hindsight). Healthcare organisations use risk registers and risk assessments to describe and quantify future patient safety risks. These tools serve a function, but they do not allow healthcare organisations and teams to foresee the next patient safety incident. In complex, adaptive systems where there are moment by moment, hour by hour changes, it is not possible to predict the patient safety incident that lurks around the next corner. The analogies between Forrest Gump’s quote and the PSIRF toolkit don’t end there. The toolkit comprises a wide-ranging set of methods and approaches, including PSII, AAR, SWARM huddles, multidisciplinary team (MDT) review, SHARE debrief, the Horizon scanning tool, SEIPS-based observation tool, interview guidance, work system scans, interaction maps and many more. The tools are complementary; AAR and SWARM huddles support reflective learning in a psychologically safe space after an incident, the MDT tool can be applied to explore pathways, processes and/or historic incidents, and the horizon scanning tool is designed to unpack emergent patient safety issues. Setting in stone which tool will be applied when (for example, by setting this out in your patient safety incident policy or plan) may create unanticipated side effects. First, the PSIRF philosophy is one of empowering learning. Dictating which tool should be applied when may negatively impact on staff willingness to engage. Healthcare organisations may unwittingly introduce boundaries on what they learn by always using the same tool. Second, mixing and matching the tools enriches learning. Comparing and contrasting ‘hard data’ and soft safety intelligence gained through observations, conversations, perceptions, gains deeper insights into patient safety improvement. Having hard and fast rules like, "Tool X will be used for incident type Y; Tool A will be applied if incident type B," means that combining tools is unlikely to occur. Another Forrest Gump-related lesson is that how a box of chocolates is packaged and presented impacts on its saleability/marketability. The same applies to the tools in the PSIRF toolkit. We see on PSIRF sharing platforms examples where root cause analysis templates have been re-branded as AAR or SWARM huddle or MDT review templates. We have also seen the (understandable) requests for PSIRF tool templates to be shared. Collaborating and sharing are integral to PSIRF. However, when sharing, stop for a moment and consider what potential negative side effects a lengthy PSIRF tool template may introduce. Poorly designed, lengthy PSIRF tool templates distract us from learning and improving. They may unwittingly create another data collection task, and/or disrupt the psychological safety of learning conversations, by creating a focus to form-filling and box-ticking. Our message is, share, pinch with pride, but do so in a discerning way whereby you stop and ask the question, "how might the design of this template impact our focus on learning and improvement?" Choosing a tool for reviewing or finding out a little more about work as done versus work as imagined is one challenge. Is this the right tool? Will it allow you to look at the issue from all perspectives? Just because you have chosen a tool doesn’t mean ‘job done’. Sometimes a combination of tools will give you a richer, more rounded view of the problem. For instance, combining the AAR and an observation can give you a more detailed view. With the AAR you get to ‘zoom in’ to the actual incident and find out all the contributing factors to why that specific incident happened (work as disclosed), but combining this with an observation you can then ‘zoom out’ and see what usually goes on day to day (work as observed). Everything. Everywhere. All at Once Don’t ask us what the storyline of the movie, ‘Everything. Everywhere. All at Once,’ is. We don’t know. A couple of the blog’s authors attempted to watch it after it won several Oscars in 2022. We gave up. But the movie title has an important message for those leading PSIRF implementation: PSIRF is a movement. Movements take time to implement. There is no expectation your approach, PSIR plan, application of the PSIRF tools, etc., will be perfect. Adopt the ‘all share, all learn’ philosophy. Build networks and collaborate. And remember, if, at times, you feel overwhelmed by the scale of the change, everyone else probably does too. Back to the Future: Past, present and future safety The Health Foundation report, The Measurement and Monitoring of Safety (Vincent, Burnett and Carthey 2013) highlighted that, predominantly, healthcare organisations focus on learning from past events (i.e., incident reports, incident investigations, claims, complaints, etc.). There is less focus on present levels of safety (i.e., is care safe today?) and even less on future safety (will care be safe in the future?). Some of the tools in the PSIRF toolkit allow us to explore present events (e.g., observations, walk-throughs, the SEIPS work system explorer). Others support consideration of future events (e.g., the horizon scanning tool). When implementing the PSIRF toolkit it is important to stop and consider whether your organisation is remaining entrenched in the ‘learning from the past’ zone. Effective incident response requires more than waiting for an incident to occur and then exploring ‘work as done.’ By balancing the effort across tools that generate insights into the present and future, as well as past events, your organisation will have a more holistic approach. And our final message relates to kindness and compassion – to yourself and others on the journey to implement PSIRF... Groundhog Day In the film Groundhog Day, Phil, a weatherman, goes to the town of Punxsutawney for an assignment and ends up re-living the same day, over again. As the movie unfolds, Phil starts to believe he is destined to spend eternity re-living the same day. Healthcare organisations must sense check whether they are reverting to a focus on error and compliance, losing sight of the focus on patient safety improvement. It will happen. Human beings are susceptible to stereotype takeover: routines, language and habits from the old world of SIF will creep into our PSIRF conversations and decision making. We all need to accept that reverting back to old habits, language and being tempted to revert to or hold onto old ways of working is a natural human response to change. Be cognizant of this. Recognise it will happen. When it does inject kindness, compassion and (where appropriate) humour to steer colleagues back to the focus on improvement. Conclusions Finally, from us. Seven movies, seven questions: Frozen: Let it go! If your organisation put its PSIRF processes under a microscope, would you still see complex, bureaucratic reporting, triage and/or decision-making requirements? In short, can your organisation demonstrate it has let the unnecessary bureaucracy go? Apollo 13: Houston we have a problem! Are you adopting the quality improvement mantra, ‘go where the will is’ and empowering PSIRF pioneers and enthusiasts to use and adapt the tools? Fences: "Some people build fences to keep people out and other people build fences to keep people in." The benefits PSIRF brings will be difficult to achieve by patient safety leaders alone. Does your organisation have patient safety teams, human factors scientists, quality improvement teams and AAR/debriefing facilitators, and other specialists working as 'one team’ to support PSIRF implementation? If no, how might you overcome barriers that prevent this? Forrest Gump: "Life is like a box of chocolates." Have you stopped and considered how the design of your PSIRF tool templates might impact on the psychological safety of the conversation healthcare teams have? Back to the Future: Past, present and future events: ‘What are your plans to ensure your organisation learns from present and future events, as well as past events? Everything. Everywhere. All at Once: "Every rejection, every disappointment has led you here to this moment". Are you rushing to get PSIRF ‘done’ or are you on a journey? Groundhog Day: Do you ever have déjà vu? How are you and others responding when conversations drift back into the old way of focusing on blaming staff; the error, non-compliance or when the ‘shoulda, woulda, coulda’ conversation re-emerges?

From Autumn 2023, NHS organisations in England are changing the way they investigate patient safety incidents. NHS England has introduced this new approach, which is called the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. However, discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident. What is a ‘patient safety incident’? A patient safety incident is when something goes wrong in a patient’s care or treatment that causes them harm or has the potential to cause harm.[1] This could be anything from being given the wrong dose of medication to getting an infection after surgery. Patient safety incidents vary in type and seriousness, and the NHS has different ways of describing particular incidents. For example, some very serious incidents are described as ‘Never events’ (things that should never happen if procedures and guidance are correctly followed).[2] How are patient safety incidents reported and recorded? Healthcare staff are required to report patient safety incidents. They generally report through their organisation’s incident reporting systems as part of a new service called Learning From Patient Safety Events (LFPSE). When they input information about an incident, they categorise it according to its type and record other relevant information. This allows incidents to be assessed for their seriousness, and a decision made about how to deal with the incident. If certain criteria are met, a patient safety incident response or investigation will be triggered. Recording incidents also allows organisations to spot trends of harm, learn the reasons why these events happen and put measures in place to stop similar incidents happening again in the same environment, or more widely across the organisation. The learning can also be reviewed and used more widely, locally by the Integrated Care System (ICS) and nationally by NHS England. Patients and family members can also record patient safety incidents using the NHS England patient and public e-form, which is currently being further developed. They are encouraged to always report incidents to healthcare staff at the time they are involved in or witness a patient safety incident. This is because just reporting it on the e-form won’t on its own generate local learning or necessarily be reported to each organisation. How is PSIRF different from the previous investigation process? PSIRF replaces the previous approach to dealing with patient safety incidents, the Serious Incident Framework (SIF), which was introduced in 2015. Under the SIF, hospitals were only required to investigate incidents that reached the threshold for being defined as ‘serious’. This sometimes meant that ‘less serious’ incidents were not investigated or learned from. For patients and families, the SIF process could be long and drawn out, and patients sometimes reported feeling ‘shut out’ from investigations. PSIRF aims to provide a more flexible, transparent and compassionate approach to learning responses and investigations, focused on understanding the different factors that contributed to incidents and ensuring organisations learn from them. NHS England states that the four key aims of PSIRF are[3]: (*Our explanation of what each aim means) Compassionate engagement and involvement of those affected by patient safety incidents. Listening to patients, families and staff involved in incidents with respect and care and involving them meaningfully throughout the process. Application of a range of system-based approaches to learning from patient safety incidents. Using tools to help understand all the different factors at play that have come together to contribute to the incident. Considered and proportionate responses to patient safety incidents. Making sure the organisation chooses actions that are appropriate to help understand what happened, learn from it and to reduce the risk of future harm. Supportive oversight focused on strengthening response system functioning and improvement. Making sure patient safety managers and leaders help all staff apply the lessons learned from incident reviews and investigations so that the team and wider organisation work in a safer way. Making sure this insight is shared for wider learning in local and national systems. Which incidents will be investigated under PSIRF? Each healthcare organisation needs to publish its own Patient Safety Incident Response Plan (PSIRP). This will outline which patient safety incidents should be reviewed and investigated and which approach should be applied in different scenarios. This document should be available to access publicly on each organisation’s website. If you have issues finding a PSIRP, you can look it up in our PSIRP finder, or contact your healthcare organisation to request a copy. Our PSIRP finder is a work in progress and we are aiming to collect PSIRPs from as many organisations as possible. If you are aware of a PSIRP that isn’t listed in our finder, please contact us so that we can add it. What practical changes will PSIRF make to how incidents are responded to and how investigations will work? PSIRF introduces and promotes a wider range of investigation approaches than were used under the SIF. Different tools, approaches and formats may be used in different circumstances, and this will be determined by an organisation's PSIRP. Some examples listed by NHS England [4] are: Patient Safety Incident Investigation (PSII)—an investigation that takes place when an incident or near-miss has significant patient safety risks and the potential for new learning. After Action Reviews (AARs)—a technique used to capture learning from an activity or event that has that has gone well or has resulted in patient harm. Thematic reviews—which aim to identify patterns in data to help answer questions, show links or identify issues. Swarm huddle—this involves staff ‘swarming’ to the site of an incident as soon as possible to analyse what happened, understand how it happened and decide what needs to be done to reduce the risk of it happening again. Who does PSIRF apply to? PSIRF applies to all NHS acute, ambulance, mental health, community, maternity and specialised services. It also applies to independent (private) healthcare providers who deliver services under the NHS standard contract. Primary care organisations and GP services aren’t required to adopt PSIRF at this stage, but they may choose to use some PSIRF approaches. What happens following a patient safety incident? How long will the investigation take? Not all patient safety incidents will result in an investigation but, when they do, the length of each investigation will vary. PSIRF aims to reduce the time investigations take, to ensure patients and families get answers more quickly and that actions are taken swifty to reduce future harm. The time an investigation takes depends on many factors, including: the complexity of the incident, including how many people are involved the extent of the harm caused the approach taken to the investigation whether other similar incidents need to be investigated at the same time the resources available to the patient safety and investigation team. Who will talk to patients and families, and when can they get involved? Hospital trusts and healthcare organisations have dedicated patient safety teams who lead on incident reviews and investigations and ensure learning is applied to improve patient safety. Depending on the organisation’s structure, patients and family members may be contacted by a range of different staff, including patient safety team staff, dedicated incident response investigators, patient and family liaison officers, and patient safety managers. Patients and family members should be contacted and involved in the process as early as possible and are likely to be asked for their account of what happened and how the incident has affected them. Sharing concerns about the PSIRF process If a patient or family member has concerns, they can raise these with the department where they are receiving care or through an organisation’s Patient Advice and Liaison Service (PALS), which offers confidential advice and support, including information about how to make a complaint. They can also contact the organisation’s patient safety team about patient safety concerns, for example, if an incident isn’t being investigated but they think it should be. Where can I find more information about PSIRF? At Patient Safety Learning, we produce and share a range of resources about PSIRF which are primarily aimed at healthcare professionals. They may also be helpful to patients and members of the public who would like more in-depth information about processes and tools. A good place to start is our PSIRF ‘Top picks’ articles: Top picks: PSIRF insights and opinions Top picks: PSIRF tools, templates and resources The NHS England website has extensive information about PSIRF, including guidance on how healthcare organisations should work with and include patients and families in investigations. The Learn Together collaborative has produced a range of resources to help patients understand PSIRF and how they might be involved in patient safety investigations. If you still have questions or would like to share your views on PSIRF, you can start a conversation in our community area or comment on this blog (you will need to join the hub for free first). Share your experiences with us We would love to hear about your views and experiences of PSIRF: If you are a patient or healthcare professional who has been involved in a PSIRF investigation, what was your experience like? What other questions do you have about how incidents are dealt with in the NHS? References Report a patient safety incident. NHS England website, last accessed 23 November 2023. Never events. NHS England website, last accessed 23 November 2023. Patient Safety Incident Response Framework. NHS England website, last accessed 20 September 2023. Patient safety learning response toolkit. NHS England website, last updated 17 August 2023.

The Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. NHS organisations in England have been implementing the framework since September 2023 and, as part of this, each trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder, available below. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. As well as sourcing PSIRPs that are easily accessible in the public domain, we submitted a Freedom of Information (FOI) request to all NHS trusts in England in November 2023. We will continue to add links to plans as they become available. If you are aware of a PSIRP that has been published that isn't yet featured, please get in touch and we will add it to the finder. Click on the links below to view each trust's PSIRP Airedale NHS Foundation Trust (Draft version, pp118-132) Alder Hey Children’s NHS Foundation Trust Ashford and St Peter’s Hospitals NHS Foundation Trust Avon and Wiltshire Mental Health Partnership NHS Trust Barking, Havering and Redbridge University Hospitals NHS Trust Barnsley Hospital NHS Foundation Trust Barts Health NHS Trust (Publicly available plan not found in check on 01/05/25) Bedfordshire Hospitals NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Berkshire Healthcare NHS Foundation Trust Birmingham and Solihull Mental Health NHS Foundation Trust Birmingham Community Healthcare NHS Foundation Trust Birmingham Women’s and Children’s NHS Foundation Trust Black Country Healthcare NHS Foundation Trust Blackpool Teaching Hospitals NHS Foundation Trust Bolton NHS Foundation Trust Bradford District Care NHS Foundation Trust Bradford Teaching Hospitals NHS Foundation Trust Bridgewater Community Healthcare NHS Foundation Trust Buckinghamshire Healthcare NHS Trust Calderdale and Huddersfield NHS Foundation Trust Cambridge University Hospitals NHS Foundation Trust Cambridgeshire and Peterborough NHS Foundation Trust Cambridgeshire Community Services NHS Trust (Publicly available plan not found in check on 01/05/25) Central and North West London NHS Foundation Trust Central London Community Healthcare NHS Trust (pp151-176) Chelsea and Westminster Hospital NHS Foundation Trust Cheshire and Wirral Partnership NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust Cornwall Partnership NHS Foundation Trust Countess of Chester Hospital NHS Foundation Trust (pp59-89) County Durham and Darlington NHS Foundation Trust Coventry and Warwickshire Partnership NHS Trust Croydon Health Services NHS Trust Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Dartford and Gravesham NHS Trust (Publicly available plan not found in check on 01/05/25) Derbyshire Community Health Services NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Devon Partnership NHS Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Dorset County Hospital NHS Foundation Trust Dorset Healthcare University NHS Foundation Trust East Cheshire NHS Trust East and North Hertfordshire NHS Trust East Kent Hospitals University NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) East Lancashire Hospitals NHS Trust East London NHS Foundation Trust (Draft version) East Midlands Ambulance Service NHS Trust East of England Ambulance Service NHS Trust East Suffolk and North Essex NHS Foundation Trust East Sussex Healthcare NHS Trust Epsom and St Helier University Hospitals NHS Trust (Publicly available plan not found in check on 01/05/25) Essex Partnership University NHS Foundation Trust Frimley Health NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Gateshead Health NHS Foundation Trust George Eliot Hospital NHS Trust Gloucestershire Health and Care NHS Foundation Trust Gloucestershire Hospitals NHS Foundation Trust Great Ormond Street Hospital For Children NHS Foundation Trust Great Western Hospitals NHS Foundation Trust Greater Manchester Mental Health NHS Foundation Trust Guy’s and St Thomas’ NHS Foundation Trust Hampshire and Isle of Wight Healthcare NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust Harrogate and District NHS Foundation Trust Herefordshire and Worcestershire Health and Care NHS Trust (Publicly available plan not found in check on 01/05/25) Hertfordshire Community NHS Trust Hertfordshire Partnership University NHS Foundation Trust Homerton Healthcare NHS Foundation Trust Hull University Teaching Hospitals NHS Trust Humber Teaching NHS Foundation Trust Imperial College Healthcare NHS Trust Isle of Wight NHS Trust (Publicly available plan not found in check on 01/05/25) James Paget University Hospitals NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Kent Community Health NHS Foundation Trust Kettering General Hospital NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) King’s College Hospital NHS Foundation Trust Kingston and Richmond NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Lancashire and South Cumbria NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds Community Healthcare NHS Trust Leeds Teaching Hospitals NHS Trust Leeds and York Partnership NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Leicestershire Partnership NHS Trust Lewisham and Greenwich NHS Trust Lincolnshire Community Health Services NHS Trust (Publicly available plan not found in check on 01/05/25) Lincolnshire Partnership NHS Foundation Trust Liverpool Heart and Chest Hospital NHS Foundation Trust Liverpool University Hospitals NHS Foundation Trust Liverpool Women’s NHS Foundation Trust London Ambulance Service NHS Trust London North West University Healthcare NHS Trust Maidstone and Tunbridge Wells NHS Trust Manchester University NHS Foundation Trust Medway NHS Foundation Trust Mersey Care NHS Foundation Trust Mersey and West Lancashire Teaching Hospitals NHS Trust Mid and South Essex NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust Midlands Partnership University NHS Foundation Trust Milton Keynes University Hospital NHS Foundation Trust Moorfields Eye Hospital NHS Foundation Trust Norfolk Community Health and Care NHS Trust Norfolk and Norwich University Hospitals NHS Foundation Trust Norfolk and Suffolk NHS Foundation Trust North Bristol NHS Trust North Cumbria Integrated Care NHS Foundation Trust North East Ambulance Service NHS Foundation Trust North East London NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) North London NHS Foundation Trust (pp148-161) Northern Care Alliance NHS Foundation Trust North Staffordshire Combined Healthcare NHS Trust North Tees and Hartlepool NHS Foundation Trust North West Ambulance Service NHS Trust (Publicly available plan not found in check on 01/05/25) North West Anglia NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Northampton General Hospital NHS Trust (Publicly available plan not found in check on 01/05/25) Northamptonshire Healthcare NHS Foundation Trust Northern Care Alliance Northern Lincolnshire and Goole NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Northumbria Healthcare NHS Foundation Trust Nottingham University Hospitals NHS Trust Nottinghamshire Healthcare NHS Foundation Trust Oxford Health NHS Foundation Trust Oxford University Hospitals NHS Foundation Trust Oxleas NHS Foundation Trust Pennine Care NHS Foundation Trust Portsmouth Hospitals University NHS Trust Queen Victoria Hospital NHS Foundation Trust Rotherham Doncaster and South Humber NHS Foundation Trust Royal Berkshire NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Royal Cornwall Hospitals NHS Trust Royal Devon University Healthcare NHS Foundation Trust Royal Free London NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust Royal Papworth Hospital NHS Foundation Trust Royal Surrey NHS Foundation Trust Royal United Hospitals Bath NHS Foundation Trust Salisbury NHS Foundation Trust Sandwell and West Birmingham Hospitals NHS Trust (Publicly available plan not found in check on 01/05/25) Sheffield Children’s NHS Foundation Trust (pp45-69) Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Shropshire Community Health NHS Trust Somerset NHS Foundation Trust South Central Ambulance Service NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) South East Coast Ambulance Service NHS Foundation Trust South London and Maudsley NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) South Tees Hospitals NHS Foundation Trust South Tyneside and Sunderland NHS Foundation Trust South Warwickshire NHS Foundation Trust South West London and St George’s Mental Health NHS Trust South West Yorkshire Partnership NHS Foundation Trust South Western Ambulance Service NHS Foundation Trust St George’s University Hospitals NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Stockport NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Sussex Healthcare NHS Trust Sussex Community NHS Foundation Trust Sussex Partnership NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Tavistock and Portman NHS Foundation Trust Tees, Esk and Wear Valleys NHS Foundation Trust Torbay and South Devon NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust (Draft version pp115-126) The Dudley Group NHS Foundation Trust The Hillingdon Hospitals NHS Foundation Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust The Princess Alexandra Hospital NHS Trust The Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust The Rotherham NHS Foundation Trust The Royal Orthopaedic Hospital NHS Foundation Trust (pp65-82) The Royal Marsden NHS Foundation Trust The Royal Wolverhampton NHS Trust (Publicly available plan not found in check on 01/05/25) The Walton Centre NHS Foundation Trust University College London Hospitals NHS Foundation Trust United Lincolnshire Hospitals NHS Trust (pp115-133) University Hospital Southampton NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) University Hospitals Bristol and Weston NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust University Hospitals of Derby and Burton NHS Foundation Trust University Hospitals Dorset NHS Foundation Trust (pp186-222) University Hospitals of Leicester NHS Trust University Hospitals of Morecambe Bay NHS Foundation Trust University Hospitals of North Midlands NHS Trust University Hospitals Plymouth NHS Trust University Hospitals Sussex NHS Foundation Trust (Publicly available plan not found in check on 01/05/25) Walsall Healthcare NHS Trust (pp258-266) Warrington and Halton Teaching Hospitals NHS Foundation Trust West Hertfordshire Teaching Hospitals NHS Trust (Publicly available plan not found in check on 01/05/25) West London NHS Trust West Midlands Ambulance Service NHS Foundation Trust West Suffolk NHS Foundation Trust Whittington Health NHS Trust Wirral Community NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Worcestershire Acute Hospitals NHS Trust Wrightington, Wigan and Leigh NHS Foundation Trust Wye Valley NHS Trust (Publicly available plan not found in check on 01/05/25) York and Scarborough Teaching Hospitals NHS Foundation Trust Yorkshire Ambulance Service NHS Trust

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). To help organisations develop their plans and transition to this new way of working, Patient Safety Learning has published a template PSIRF Risk Register and Risk Management Plan. PSIRF is a significant organisational and culture change programme and organisations need to produce certain documents to show how they are implementing it locally. This includes a Board-approved Patient Safety Incident Response Plan (PSIRP), outlining their patient safety priorities and how they will adopt the new tools and methods for: incident review staff engagement and training, patient and family engagement culture change. To ensure patient safety is at the heart of these implementation plans, they will need to be informed by a risk assessment. PSIRF Risk Register and Risk Management Plan Last year, working with members of the Patient Safety Management Network and others, Patient Safety Learning developed a PSIRF Risk Register and Risk Management Plan. This has been used to support members of the network as they transition to PSIRF. We have now published an updated version, here on our patient safety platform – the hub, free and available to anyone. It’s a generic risk assessment and has been shared in a format that allows organisations to adapt to meet their local circumstances and priorities. This tool is designed to help leaders in the NHS and independent sector implement PSIRF safely. You can download this by opening the attachment on this page. Join our community If you would like to join our global online community of people passionate about patient safety, please sign up to the hub here. It’s free and easy to do. If you would like to join the Patient Safety Management Network or another safety-focused network, tick the relevant box when you register for the hub. Our blog 7 reasons to join the hub will give you a flavour of our how becoming a member could benefit you. Share your views Are you involved in the implementation of PSIRF? How has the process been? What has helped you to transition? What tools would help you moving forward? What do you think of the tools shared here by Patient Safety Learning? Share your thoughts and experiences by commenting below (you’ll need to sign up first for free), or by getting in touch with us at [email protected]. Related content Top picks: PSIRF tools, templates and examples Top picks: PSIRF insights and opinions Is the NHS ready for PSIRF? A blog by Chris Elston Patient Safety Education Network.