PSIRF: a fundamental shift in how the NHS responds to patient safety incidents

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Melanie Ottewill, National Investigator and Senior Investigation Science Educator at HSIB. — Melanie Ottewill, Senior Safety Investigator and Senior Investigation Science Educator.

The Patient Safety Incident Response Framework (PSIRF), which replaces the Serious Incident Framework (SIF), was published in August 2022. For those involved in incident investigation in the NHS, it’s fair to say its launch marked a seminal moment. As Tracey made clear, PSIRF fundamentally shifts how the NHS responds to patient safety incidents for learning and improvement.

Proportionate response to patient safety incidents

Unlike the SIF, the PSIRF is not an investigation framework that prescribes what to investigate. There is no distinction made between ‘patient safety incidents’ and ‘Serious Incidents’. As such it removes the ‘Serious Incidents’ classification and the threshold for it.

Instead, the PSIRF promotes a proportionate approach to responding to patient safety incidents by ensuring resources allocated to investigating and learning are balanced with those needed to deliver improvement. This means that organisations can choose which incidents they prioritise for a full investigation, and which they will respond to differently – for example, by conducting a multidisciplinary review, or facilitated debrief.

As an ex-head of a patient safety team in a large acute NHS trust, this move away from the requirement for repeated investigations of similar incidents, yielding limited new learning, feels like a breath of fresh air.

Patient safety incident response plan

As Tracey explained, the starting point for organisations is to produce a patient safety incident response plan. This will detail how different types of incidents will be responded to, based on the potential for learning, and mindful of existing safety improvement work.

The plan should be informed by an interrogation of multiple sources of data and other safety intelligence. For example, incident data, complaints, claims, audits and focus groups with staff.

Whilst organisations can choose how they will respond to different types of incidents, Tracey emphasised the need for all learning responses to demonstrate a system-based approach. That is, an approach which includes consideration of all the factors that influence staff actions and decisions, such as the equipment, technology, environment and organisational culture.

Guides and tools

Guides and tools have been published alongside PSIRF to support staff to do this, some of which were developed in collaboration with HSIB, including involving patients, families and staff guidance and a range of investigation education courses. Most of the tools could also be used proactively to understand safety issues before any harmful incidents occur.

PSIRF sets a requirement for staff who lead learning responses to have received at least two days training in a systems approach to learning from patient safety incidents. HSIB’s Level 2 course meets the requirements and already over 1,000 NHS staff in England have enrolled, showing the huge demand and desire from staff to develop their skills and knowledge.

In addition, our investigation education team are developing a number of stand-alone modules to further support staff – a module on the use of the Systems Engineering Initiative for Patient Safety (SEIPS), and another on thematic analysis being examples.

Compassionate involvement

Compassionate engagement and involvement of those affected by patient safety incidents is another core element of PSIRF. Tracey highlighted aspects of the national guidance to support this. For those whose role is to lead engagement with staff, patients and families, the guidance provides a practical handrail through the different stages of engagement - from planning the first contact through to closure.

Importantly, for the first time, staff, patients and families are brought together in one document. This reflects recognition of the shared needs and approach to engagement that should be adopted. Again, NHS England and HSIB worked collaboratively on this document. The one-day training requirement for engagement leads stated in PSIRF is provided by our investigation education team.

Effective oversight

Ensuring the aims of PSIRF are met will require effective oversight. But, as Tracey explained, this oversight will be of a different kind than the command and control traditionally experienced.

Typically, under SIF, oversight included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF will focus on engagement and empowerment to strengthen response system functioning and promote a culture of improvement.

The crucial role of oversight is reflected in the requirement for training and the detailing of responsibilities for those in these roles. Again, HSIB’s investigation education team are developing an oversight course to meet PSIRF requirements which will be available later this year.

Cultural shift

PSIRF heralds a significant cultural shift. Like all cultural shifts, it will not be easy and will take time. But the potential gains for patients and families, for staff and ultimately for safety are significant. There could be no bigger incentive.