Patient Safety Incident Response Framework (PSIRF) Staff handbook

Patient Safety Incident Response Framework (PSIRF)

Staff handbook

Key contacts

Liz Hall

Head of Patient Safety and Patient Safety Specialist

Email: Liz.hall@southernhealth.nhs.uk

Adam Osborne

Patient Safety Investigation Lead

Email: Adam.Osborne@southernhealth.nhs.uk

Magda Wroblewska-Trojanowicz

Family Liaison Officer

Email: magda.wroblewska-trojanowicz@southernhealth.nhs.uk

Georgia Walker

Quality and Patient Safety Project Manager

Email: georgia.walker@southernhealth.nhs.uk

Beth Ford

Patient Safety Partner Lead

Email: Beth.ford@southernhealth.nhs.uk

Patient Safety Team

Email: Patientsafetyteam@southernhealth.nhs.uk

Patient Safety Partners

Email: Patientsafetypartners@southernhealth.nhs.uk

What is PSIRF

NHS England has published the new Patient Safety Incident Response Framework (PSIRF) outlining how NHS organisations should respond to patient safety incidents for the purpose of learning and improvement

The framework will replace the current Serious Incident Response Framework by Autumn 2023, and represents a significant shift in the way the NHS responds to patient safety incidents, centring on compassion and involving those affected; system based approaches to learning and improvement; considered and proportionate responses; and supportive oversight.

PSIRF is a major step towards improving safety management across the healthcare system in England and will greatly support the NHS to embed the key principles of a patient safety culture. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals; allowing for more effective learning and improvement, and ultimately making NHS care safer for patients.

PSIRF removes the requirement that all/only incidents meeting the criteria of a ‘serious incident’ are investigated. It allows for other incidents to be reviewed and for a learning response to focus on areas with the greatest potential for patient safety improvement.

Continuing to learn and evolve over future years

What does PSIRF hope to achieve?

Improved experience for those affected:

Expectations are clearly set for informing, involving, and supporting those affected by patient safety incidents, particularly patients, families and staff.

Aligned with ongoing research around improving patient and family involvement

Better range of methods for learning:

Promotes a range of methods for responding to and learning from patient safety incidents

Moves away from Root Cause Analysis (RCA) , towards a system-based approach to learning.

Timelines are more flexible and set in consultation with the patient and/or family.

Quality of response and resulting improvement work is the priority

More proportionate and effective response:

Changes blunt rules to determine what to learn from and what not to learn from.

Resource planning based on thorough understanding of patient safety incident profiles and ongoing improvement activity. Supports organisations to be more proportionate, sensitive and considered in their approach.

Strengthened governance and oversight:

Regulators and bodies like Integrated Care Board (ICB) and Commissioners will consider the strength and effectiveness of organisations’ incident response processes. Makes leaders of organisations providing healthcare accountable for how their organisation responds and improves following patient safety incidents

Just and learning culture behaviours

A just and learning culture underpins the PSIRF. It recognises that we work in a highly complex environment where things do not always go to plan

It allows us to learn using a fair, compassionate and accountable approach that assumes good intention and understands the impact of the system and why decisions made sense at the time. It allows staff to speak up and it asks “what happened and how do we learn?”

Focusing on the “what” and not the “who” enables us to draw out the good practice within incidents in order to learn from positive events as well as learning from when things go wrong.

A variety of learning response tools will be used to draw out learning and encourage a culture of continuous improvement.

Investigation approach

Quality is the priority, selection of incidents based on potential for new learning and complexity of the system

Systems based Patient Safety Incident Investigation (PSII)

Timeframe

Flexible and set in consultation with the patient and/or family

Investigator expertise, experience, time and authority:

Must be led by those trained in PSII with authority to act autonomously with dedicated time and resource

What does it mean for me?

You will be fully supported during an incident

You will notice that the focus of incidents will change from errors to an opportunity for learning and development.

You will be given the full opportunity to be involved in the review of the incident

You will be fully able to focus on the human factors of an incident

You will be able to work with others across the trust to identify system learning

You will be empowered to showcase learning from incidents

You will be able to choose to get involved with Patient Safety Initiatives

You will be able to mentor colleagues to increase learning

What do I need to do?

You will need to complete the level 1 of the patient safety syllabus via LEaD - Level 1 eLfH-2119

You will need to complete the level 2 of the patient safety syllabus via LEaD - System thinking and risk: eLfH-2121 and Human Factors and safety culture: eLfH-2122

You will be encouraged to role model a just and learning culture

You will be offered training from the patient safety team on conducting learning responses where needed

You will be supported and encouraged to speak up about patient safety concerns

Four key aims of PSIRF

Application of a range of system-based approaches to learning from patient safety incidents

Considered and proportionate responses to patient safety incidents

Compassionate engagement and involvement of those affected by patient safety incidents

Supportive oversight focused on strengthening response system functioning and improvement

Find out more at: Our Staff Portal

www.england.nhs.uk/patient-safety/incident-response-framework

Project Phases

Governance and quality monitoring

We are beginning to define the governance structures and the new way of working within PSIRF in collaboration with the ICB.

Patient safety incident response planning Transition

We are understanding our patient safety incident profile, improvement profile and available resources This information will be utilised to populate the PSIRF plan and policy

Curation and agreement of the policy and plan

Drafting and agreeing the PSIRF policy and plan based on the findings from work undertaken in preceding phases

We will transition in October 2023 and will continue to adapt and learn as the designed systems and processes are put in place.

Word Search Fun

CentralInvestigationTeam@southernhealth

Family Liaison Service

familyliaison@southernhealth.nhs.uk

Patient Safety Clinical Leads

Portsmouth & South East

Jocelyn Franey jocelyn.franey@southernhealth.nhs.uk

Southampton

South West

Helen Spencer (nee Griffiths) helen.griffiths@southernhealth.nhs.uk

Mid & North

Francesca Savidge francesca.savidge@southernhealth.nhs.uk

Specialist (CAMHS & Children's)

Sophie McFarlane sophie mcfarlane@southernhealth nhs uk

Specialist (Adults Forensic & Learning Disabilities) –

Michelle Watson Michelle.Watson@southernhealth.nhs.uk Ulysses

ulysses@southernhealth nhs uk