Related Sector: Health & Social Care

The Patient Safety Incident Response Framework (PSIRF), which replaced the Serious Incident Framework, was published last August. It heralded a fundamental cultural shift in the way that the NHS responds to patient safety incidents − particularly with regards to approach and safety measures.

"The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen – including the factors which contribute to them.” - Aidan Fowler, National Director of Patient Safety, NHS England.

There was a 12-month lead-in period for organisations to prepare for the transition to PSIRF. This has now past and the PSIRF is a contractual requirement for mandatory services, including acute, ambulance, mental health, and community care providers.

We recently sat down with Bond Solon subject matter expert and former Senior Manager at Belfast Health and Social Care Trust, Patrick Keenan, to find out how more about the intention behind this cultural shift, the practical implications of PSIRF patients and health workers, and why it is important to ensure that all staff are educated on the new principles from the outset.

1. What factors led to the introduction of the PSIRF, and an overhaul of an existing framework that had been place for almost ten years?

This new strategy and approach to patient safety is the latest iteration of the continuation in the evolution of patient safety investigation and management. Building on the previous experience of patient safety and serious incident investigation; this new approach − in many key respects − consolidates the valuable lessons from past investigation processes. It moves forward with a re-emphasis on the importance of meaningful engagement with all key stakeholders in a patient safety incident.

Additionally, organisations must now:

  • Identify and implement the strategies to reduce the likelihood or reoccurrence of past incidents (as well as identifying the significant factors that contributed to them).
  • Demonstrate that real, credible, and practical measures have in fact been introduced during patient safety incident investigations.

2. The key focus of the PSIRF is to engage and involve patients, families and staff following a patient safety incident – what does this mean for all parties on a practical level?

This engagement has always been a necessary yet often poorly implemented feature of the patient safety investigation process. There are real sensitivities and practicalities associated with this communication. Addressing the expectations of all stakeholders requires diplomacy and honesty in equal measures. The accessibility of a key point of contact and the demonstration of transparency, timeliness and equity in the provision of information borne from a patient safety incident will present challenges to those delivering this information - not least of all the requirement to retain and exhibit empathy.

3. What other key changes have been implemented by the PSIRF?

The introduction of more robust guidance and the availability of an agreed template should promote consistency in reporting and sharing lessons learned. There is a recognition and recommitment to the process of supporting the identification and proportionate response to managing patient safety incidents.

Organisations will have to demonstrate not just where they have identified aspects of service/care deficiency but provide tangible evidence of change and improvement as a consequence of lessons learned. The significance of timely meaningful and unconditional apologies made in response to identified sub-optimal care has also been reinforced.

4. How important is it for those responding to patient safety incidents to be able to implement the new principles correctly at the point of incident?

This new process and the embedding of its key elements are a contractual obligation for secondary care and a real expectation for those involved in the provision of primary care. In addition, the importance of demonstrating learning for improvement is crucial. Evidence-based data derived from the investigation and analysis of patient safety incidents will be collated and translated into practical learning that is communicated and utilised inside that organisation and/or shared on a national basis.

5. You’ve been involved in designing and delivering training for those involved in serious/critical incident investigations – what can delegates expect from our training?

Our training has always focused on:

  • Getting the investigation process correct.
  • Ensuring that all the evidence is identified and collected/collated to inform the process of dealing with any patient safety incident review.

The emphasis on the key principles of natural justice delivered in our training; fairness, honesty, open-mindedness, impartiality, and empathy align directly with the core principles of engagement outlined in the PSIRF guidance.

In addition, the delivery of time-sensitive effective investigations producing, transparent, reliable findings, which are communicated sensitively and honestly to all parties are key themes in our training. This again sits naturally with the ethos of this enhanced approach to improving the safe journey for those involved in health and social care, irrespective whether you are the provider or the recipient of such care.  

Author: Meera Shah

This article was first published on the 6 October 2023

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