University Hospitals Birmingham NHS Foundation Trust

During my career, I have seen the investigation, management and implementation of corrective actions for countless patient safety incidents. Recently, I have been reflecting on the top words that come to mind when I think of these cases: distress, questions, blame, retribution, and costs. Words like safety, improvement, learning and closure feature much less frequently.

Why? Historically, clinical governance and medicolegal processes in large health service organisations have placed a heavy emphasis on being defensive. An apology, even as an expression of regret for an unintended outcome, may have been viewed as a risk to the system, the organisation and the individual. But medicine is rarely black or white; most of our practice happens in those grey areas, where decisions are made by balancing medical knowledge, clinician experience, the information available at the time, and patient preferences.

There is no surgery or tablet with zero complications or side effects. It should be no surprise that things sometimes do not go as planned. When unintended outcomes happen, openness, honesty, transparency and learning are needed. These are the ingredients for a safer, more effective, more caring, more responsive and better-led healthcare organisation. One which delivers better patient satisfaction, receives fewer complaints and spends less on litigation. A complete change of mindset is needed.

The National Health Service in England has recognised for some time that top-heavy investigations can sometimes focus too much on liability and do not enough on understanding how and why incidents happen or contributory factors. This can lead to a failure to prevent recurrence.

The Patient Safety Incident Response Framework (PSIRF) marks a significant shift in how patient safety incidents are dealt with. In this article, we explore the key considerations for adopting PSIRF within an organisation and its impact.

“A crucial aspect of PSIRF is the engagement and involvement of those affected by patient safety incidents”

PSIRF is a transformative approach adopted by NHS England to enhance patient safety through effective response to patient safety incidents. It signifies a paradigm shift from the previous Serious Incident Framework established in 2015, aiming to foster a culture of learning and improvement rather than blame and punishment.

At the heart of PSIRF is the commitment to understanding how incidents occur, including the contributory factors, rather than merely documenting them. This framework encourages a system-based approach to incident response, ensuring that lessons are learned and that similar incidents are prevented in the future.

PSIRF integrates four key aims to revolutionise patient safety incident response:

Compassionate engagement with patients, families, and staff affected by incidents. Application of system-based approaches for learning from incidents.

Proportionate responses to incidents based on their severity and potential for learning. Supportive oversight to strengthen system functioning and continuous improvement.

A crucial aspect of PSIRF is the engagement and involvement of those affected by patient safety incidents. This involves transparent communication and support for patients and families, ensuring that their experiences are heard and valued in the process of learning and improvement.

The framework provides a structured approach to responding to patient safety incidents, emphasising the need for a consistent and methodical analysis to identify root causes and systemic issues. This process is supported by a toolkit and guidance documents that help organisations implement the framework effectively.

The introduction of PSIRF has been welcomed by healthcare professionals and patient safety advocates alike. It aligns with the broader NHS Patient Safety Strategy and is seen as a significant step towards establishing a robust safety management system across the NHS.

Prevention of safety incidents is a continuous process, requiring the engagement of staff as well as patients, and does not simply start and end with the investigation.

The Patient Safety Incident Response Framework represents a significant advancement in the way the NHS addresses patient safety incidents. By focusing on learning, compassionate engagement, and system-based responses, PSIRF aims to create a safer healthcare environment where every incident is an opportunity for improvement. As it continues to be implemented and refined, PSIRF holds the promise of a future where patient safety is at the forefront of healthcare delivery, not just in the NHS, but as a model that could apply to all large healthcare systems.