Patient Safety

The Patient Safety Incident Response Framework (PSIRF) was published by NHS England in August 2022 with a 12-18 month timeframe for providers of NHS-funded secondary care to implement it.

PSIRF is the new approach to maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. It advocates a co-ordinated and data-driven approach to patient safety incident response that prioritises compassionate engagement with those affected by patient safety incidents. It embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.

There are four key principles of 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.
  • Supportive oversight focused on strengthening response system functioning and improvement.

Under PSIRF, providers of NHS-funded secondary care are required to create a Patient Safety Incident Response Policy that describes the systems and processes in place to learn and improve following a patient safety incident. As well as an annual Patient Safety Incident Response Plan (PSIRP) that describes their patient safety incident profile, and how they intend to respond to patient safety incidents, including the methods to be applied, and the rationale.

NHS Somerset is required to ensure our Somerset providers’ PSIRPs and policies reflect a set of patient safety incident response standards.

  • Ensure patient safety and quality improvement systems and processes align.
  • Promote a just culture.
  • Effective communication and information sharing.
  • Clear governance and reporting structures which encourage openness and transparency.
  • Collaboration with stakeholders.

We have been working on implementing PSIRF with our providers here in Somerset and are now into the embedding phase.

The ways of reporting patient safety incidents is changing. Traditional ‘Serious Incident’ data is being replaced with safety measures that triangulate both qualitative and quantitative data, to reflect a clear understanding of the effectiveness of the patient safety incident response systems, governance, and oversight. NHS Somerset will work collaboratively with our providers if incident intelligence demonstrates that ongoing improvement work is not having the desired effect, to assess the systems and processes in place and support safety improvement. We will support coordination of multi-agency learning responses. And we will endeavour to share learning and good practice across organisations.

Under this new framework there is a stronger focus on improving and learning from patient safety incidents, with the ultimate aim to always be improving, and to keep our Somerset patients safe.

Our NHS Somerset Patient Safety Incident Response Policy is available here, and our Patient Safety Incident Response Plan here which set out our implementation journey here in Somerset and how we intend to support our Somerset providers to respond to and learn from patient safety events.

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