The Patient Safety Incident Response Framework

The much anticipated Patient Safety Incident Response Framework (PSIRF) was published in August. It is envisaged that service providers under the NHS Standard Contract (which includes Trust’s providing acute, ambulance, mental health and community healthcare services) will have moved across from the old style Serious Incident Framework (SIF) to the new PSIRF by autumn 2023. 

The concern about the old SIF approach was that it focused too much on “a simplistic, linear identification of a single cause”. In practice this often resulted in repeatedly investigating similar type incidents whilst failing to identify and implement a solution.

The aim of the new framework is to improve patient safety by responding to patient safety incidents in a way that enables the organisation to learn lessons and to adapt and change. Each organisation will have to develop its own PSIRP (Patient Safety Incident Response Plan) but the guiding principles of the new framework will be:

• That there should be compassionate engagement with those affected – the patients, families and staff involved;
• That there is a pro-active strategy for learning from patient incidents (LFPSE). This will involve better use of data to identify what is working well (or not);
• One of the underpinning principles of PSIRF is that there should be fewer investigations but that those that take place are more thorough and are conducted by properly trained teams of investigators. This will inevitably involve having a broader range of responses to incidents not just formal investigations. There will be greater focus on those areas where the most impact can be achieved and whilst some incidents will qualify for a Patient Safety Incident Investigation (PSII) others will not and an alternative more proportionate response will be appropriate. In those types of cases case note reviews, open conversations or after-action reviews might take place. In other cases, a “do not investigate” or “no response required” may be appropriate. The PSIRP will have to set out the criteria applicable to determine the approach in each case;
• Where a PSII is deemed appropriate the investigation timescales will be more flexible. The previous 60 days timeline is replaced by individual PSII timescales which are to be agreed in consultation with the patient and/or family affected. That said it is envisaged that investigations should average three months and never exceed six months.
• There should be supportive oversight of the process which acknowledges system failings rather than casting blame on individuals.

All of this is being implemented at a challenging time when resources are often stretched. The issues which organisations must be wary of include:

• Guarding against business as usual. It will be important to avoid investigating and reviewing incidents as before and simply applying a new label to the old approach;
• Staff must be made aware of the new processes and how to implement them across the organisation;
• Ensuring staff can access the right training;
• To have an adequately resourced system in place to determine which incidents need investigating and which are more suited to an alternative approach;
• To ensure that where a PSII takes place that it is adequately resourced to ensure that its recommendations are meaningful;
• The management teams within the Trust will need to reach a point where they are comfortable with a system where there are a reduced number of investigated incidents;
• Perhaps most importantly of all there will be a need to ensure that patients and families feel that their concerns have been heard when there is no PSII. Failures in this regard could in fact lead to an increase in litigation where families become concerned that they are not getting answers.

Concluding Comments

The PSIRF is a clear departure from the previous patient safety regime and its implementation will involve designing a whole new set of systems and processes. Whilst implementation may well be challenging the aim is that once in place the framework will address patient safety concerns in a more flexible and autonomous way so that effective learning is achieved in a way that best suits the needs of each organisation.

Webinar - Patient Safety Incident Response Framework (PSIRF): Insight from an Early Adopter. 27 October 10am

For more information join Bevan Brittan Partner & Head of Health (NHS) Joanna Lloyd for a question-and-answer session with Helen Woolford, Head of Quality, Improvement and Learning and an Early Adopter of the Patient Safety Incident Response Framework at London Ambulance Service NHS Trust.

Helen will share experiences with the audience and provide insight into how PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents.

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