Patient Safety

The Patient Safety Incident Response Framework (PSIRF)

The Patient Safety Incident Response Framework (PSIRF) is the way the NHS now looks at patient safety incidents. It helps us learn from things that go wrong so we can make care safer for everyone. (PSIRF replaces the old Serious Incident Framework.)

Instead of focusing on blame, we focus on understanding what happened and why, so that we can try and stop the incident from happening again.

PSIRF has four main aims:

• Compassionate engagement. We listen to and support patients, families, and staff affected by incidents.
• System-based learning. We look at how our systems and processes work, not just individual actions.
• Proportionate responses. We respond in ways that match the seriousness of the incident.
• Supportive oversight. We make sure learning leads to real improvements.

This approach helps us to develop a culture which is fair and open, and where people feel safe to raise concerns, so we can learn from mistakes and incidents to make our services safer.

What is a patient safety incident?

A patient safety incident is when something unexpected happens during care that could or has harmed a patient. This could be a mistake, a missed step, or something that didn’t go as planned.

How we respond to incidents

Not every incident needs a long investigation. Sometimes we already know what went wrong and how to fix it. In those cases, we focus on making changes quickly.

When an investigation is needed, it’s called a Patient Safety Incident Investigation (PSII). These help us understand complex issues and make bigger improvements.

We also use other ways to learn, like:

• Team debriefs
• After Action Reviews
• Multidisciplinary team meetings
• Early Learning Reviews

What happens if you are affected by an incident?

When things do go wrong, we want to involve patients, their families and carers. This helps us understand what went wrong, and what we can learn.

Patients, families and staff should always be treated with compassion, and given the opportunity to be part of any investigation.

If you or someone you care about is involved in an incident, we will contact you. We will offer you the chance to talk about what happened. We will

• Listen to your concerns
• Answer your questions
• Explain what will happen next
• Keep you involved in the process

You can also contact the Patient Advice and Liaison Service (PALS) for help and support.