Patient Safety Incident Response Framework

The Patient Safety Incident Response Framework (PSIRF), is the new NHS approach for responding to incidents for the purpose of learning and improving patient safety.

PSIRF promotes a proportionate response to patient safety incidents by ensuring resources allocated to learning are balanced with those needed to deliver improvement.

The national framework defines a number of national priorities, for example Never Events, which we must investigate locally through an in-depth systems-based investigation, called a Patient Safety Incident Investigation (PSII).

This focuses on addressing causal factors and uses improvement science to prevent or continuously and measurably reduce repeat patient safety risks and incidents.

In addition, we have identified two local priorities for PSII based on highest levels of patient safety risk identified from a minimum three years data analysis.

These are :

• Sub Optimal Care : Incidents affecting patients where care is being managed between >1 clinical specialty, where management resulted in the patient being transferred to multiple wards and there was a failure or delay in acting on an escalation of a deteriorating clinical situation
• Missed or Delay to Diagnosis : Patients under the care of the Emergency Department or Medical Specialties where a missed or delay in diagnosis leads to a significant delay in the initiation of essential treatment.

Incidents not meeting these priorities, but where there is potential for significant learning to be identified, will have a proportionate learning response to review what has not gone as expected, our Patient Safety Incident Response Plan (PSIRP) sets out what we will investigate and how.

Our Patient Safety Response Policy supports development and maintenance of an effective patient safety incident response system that integrates the four key aims of the PSIRF:

• 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 and safety issues.
• supportive oversight focused on strengthening response system functioning and improvement.