The Patient Safety Incident Response Framework has Launched

Who is affected?

The Patient Safety Incident Response Framework (“PSIRF”) is mandatory for services providers under the NHS Standard Contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services as well as independent healthcare providers who provide NHS services under the Standard Contract. Primary care providers may also wish to adopt PSIRF, but it is not currently a requirement.

What is it?

The PSIRF sets out NHS England’s approach to developing systems and processes for responding to patient safety incidents with the aims of improving patient safety and learning lessons. It is replacing the Serious Incident Framework (“SIF”) established in 2015.

Patient safety incidents are unintended or unexpected events (including omissions) in healthcare that could have or did harm one or more patients. It is acknowledged there should be a proportionate approach to reviewing incidents, moving away from individual blame.

There remain mandatory events where an investigation under the PSIRF is required. These include deaths of patients detained under the Mental Health Act 1983 or those where the Mental Capacity Act 2005 applies, deaths thought more likely than not to be due to problems in care and incidents meeting the Never Events criteria 2018 (or its replacement).

There are four key aims of the PSIRF:

1. Compassionate engagement and involvement of those affected
2. Application of a range of system-based approached to learning
3. Considered and proportionate responses
4. Supportive oversight

There are now national tools and templates to help organisations to develop “systems thinking” approaches which should ultimately improve patient care across the NHS. Please note the SEIPS framework for understanding outcomes is endorsed by the PSIRF but organisations can select their preferred systems based framework to deliver their patient safety incident response.

The PSIRF also recommends that NHS providers, ICBs and regulators work together to design their systems to allow organisations to show improvement through a system of engagement and empowerment.

What happens next?

It is expected that the transition away from the SIF to PSIF should start in September 2022, completing in Autumn 2023.

Organisations should:

• Consider the experiences reported by the early adopters to inform their approach to implementation.
• Utilise the NHS England Preparation Guides and Future NHS resources.
• Sign up to the NHS England webinar if possible: Implementing the new Patient Safety Incident Response Framework (online webinar) | NHS England Events.
• Identify a PSIRF executive lead – this may be the person with overarching responsibility for quality or patient safety. They must be a board member or hold the equivalent role in the leadership team as well as being appropriately qualified to hold this role.
• Set the PSIRF executive lead’s responsibilities so that the organisation can ensure there is oversight of patient safety reporting and review and that appropriate mechanisms are in place to monitor and review patient safety (including through governance arrangement, staff support and training).
• Develop a PSIRF policy/protocol setting out how the framework will be achieved in practice, reporting requirements to the Board, governance and auditing mechanisms and the process by which the PSIRF’s aims will be embedded into the organisation’s culture. Templates for your own patient safety incident response policy and plan can be found here: NHS England » Patient Safety Incident Response Framework and supporting guidance.
• Work with other organisations to understand what systems and processes are working well in practice, as well as working with local partners to develop a consistent approach, including with the ICB.

Additional Supporting documents

The PSIRF is supported by further detail provided in four guidance documents:

1. Engaging and involving patients, families and staff following a patient safety incident
2. Guide to responding proportionately to patient safety incidents
3. Oversight roles and responsibilities specification
4. Patient safety incident response standards

How can we help?

Bevan Brittan LLP has wide experience of assisting clients with patient safety incident responses and we have worked alongside a number of the early adopters through their PSIRF journey.  Should you require any support or assistance in relation to the implementation of the PSIRF, including the adoption of new polices/procedures or job descriptions, please do not hesitate to get in touch.