NHS England has published its new Patient Safety Incident Response Framework (PSIRF), which aims to encourage learning and thereby prevent similar incidents from occurring in the future.
The PSIRF sets out its approach to developing and maintaining effective systems and processes for responding to patient safety incidents, which replaces the existing Serious Incident Framework, with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
The intention is to support the development and maintenance of an effective patient safety incident response system that integrates four key aims:
- Compassionate engagement and involvement of those affected by patient safety incidents.
- Application of a range of system-based approaches to learning from patient safety incidents.
- Considered and proportionate responses to patient safety incidents.
- Supportive oversight focused on strengthening response system functioning and improvement.
Commenting on this, Patient Safety Learning’s Chief Executive Helen Hughes said: “Too often the existing approach to patient safety investigation in the NHS does not result in the learning and improvement needed to prevent future incidents of avoidable harm.
"The new Patient Safety Investigation Response Framework places an emphasis on individual organisations assessing their patient safety risks, prioritising resources and developing new investigation plans based on this. It also makes a welcome acknowledgement of the importance of engaging patients and families as part of the investigation process.
"To ensure that reviews and investigations result in a clear understanding of the causal factors of harm and lead to safety improvements, there will need to be a significant training programme for staff in a range of human factors informed approaches.
"What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. NHS England have now provided a set of tools and a timetable for this, however ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.”