Patient Safety - PSIRF
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. The pilot for applying PSIRF in primary care is taking place across 2024/25.
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 replaces the Serious Incident Framework (SIF) 2015. This new framework 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 a 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. These are living documents which will be reviewed approximately every 18 months to ensure that the identified patient safety themes, incident response methods, and improvement plans remain applicable.
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.
Providers transition from working under the SIF to the PSIRF once their Patient Safety Incident Response Policy and Patient Safety Incident Response Plan (PSIRP) are reviewed and agreed by their lead/coordinating ICB, and subsequently published on their organisation's website.
The ICB’s responsibility within the patient safety events space has moved away from seeking assurance and quality reviewing providers’ individual incident responses, to instead be that of the following:
- Established roles, responsibilities, and processes for oversight.
- Established mechanisms for escalation of incidents and risks that may require support or action at ICB level.
- Understanding and reviewing providers’ patient safety incident and improvement profiles.
- Working collaboratively with 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.
- Supporting coordination of multi-agency learning responses.
- Sharing learning and good practice across organisations.
We have been supporting our providers here in Somerset with the transition to PSIRF.
NHS Somerset will work collaboratively with our providers if incident intelligence demonstrates that ongoing improvement work in relation to a patient safety area of concern 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 will endeavour to share learning and good practice across organisations, with the ultimate goal of ensuring our system provides high quality care to our population and keeps the patients of Somerset as safe as possible.
Our own NHS Somerset Patient Safety Incident Response Policy is available by clicking the button at the top of this page, as well as our Patient Safety Incident Response Plan, and an easy-read version of this. These documents 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.
