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This patient safety incident response plan sets out how we intend to respond to patient safety incidents over the next of 12 to 18 months, building on the work as an early adopter and implementing the new patient safety framework over the last two years.
Patient Safety Plan Template. Step 1: Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing
Approaches to involving patients in their own healthcare and safety can include: Encouraging patients to ask questions by: asking them directly if they have any queries about their care. providing leaflets, videos and apps to encourage patients to ask questions or raise issues with professionals.
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Jul 23, 2024 · An organisation’s patient safety incident response policy should describe its overall approach to responding to and learning from patient safety incidents for improvement and identify the systems and processes in place to integrate the four key principles of PSIRF.
- Key points
- Background
- Achieving effective learning and improvement using PSIRF
- What are trusts required to do?
- Patient safety incident response policy
- Patient safety incident response plan
- PSIRF and inequalities
- Accompanying guidance
- Oversight roles and responsibilities specification
- Oversight approach
- Organisational responsibilities
- Other types of review and/or investigation
- Improving incident response through collaborative external review
- Guide to responding proportionately to patient safety incidents
- What is a ‘system-based approach’ to learning?
- What does ‘considered and proportionate response’ mean?
- Patient safety incident response activity
- Patient safety incident response standards
- Policy, planning and oversight
- Competence and capacity
- Engagement and involvement of those affected by patient safety incidents
- Proportionate responses
- Training requirements
- Engaging and involving patients, families and staff following a patient safety incident
- Creating the right foundations
- Engagement and involvement process
- NHS Providers view
- NHS Providers press statement
The Patient Safety Incident Response Framework (PSIRF) – a core element of the NHS Patient Safety Strategy – establishes the NHS’s approach to the development and maintenance of mechanisms for responding to patient safety incidents (PSIs) to maximise learning and improvement. The PSIRF is a contractual requirement and is mandatory for providers o...
The PSIRF establishes the NHS’s approach to the development and maintenance of effective systems and processes for responding to patient safety incidents (PSIs) in a way which facilitates learning and improvements to patient safety. It replaces the existing SIF, with the aim of focusing on learning within and across organisations. The PSIRF aims to...
The PSIRF’s core document brings together the following four main aims: 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 ...
The PSIRF is a contractual requirement under the NHS Standard Contract and is mandatory for the provision of services under this contract, including all acute, mental health, community and ambulance trusts, as well as maternity and specialised services across the NHS. Organisations are required to apply and embed the PSIRF into the development and ...
This should describe an organisation’s overall approach to responding to and learning from PSIs, as well as to identify the systems and processes in place to integrate the four key aims of PSIRF. It should outline how those affected by an incident will be engaged, what governance processes for oversight are in place and how learning responses are t...
This should specify how an organisation will maximise learning and improvement. It should be based on a thorough understanding of the organisation’s patient safety incident profile, ongoing improvement priorities, available resources and the priorities of stakeholders, including patients and local Healthwatch. A national plan template is available....
The PSIRF has been developed to provide a mechanism to help address inequalities in patient safety through the following: Its flexible approach makes it easier to address concerns specific to health inequalities, and it provides the opportunity to learn from PSIs that did not meet the definition of a ‘serious incident’; It prompts consideration of ...
Alongside the core PSIRF document, the following pieces of accompanying guidance provide information for trusts to support implementation: Preparation guide Oversight roles and responsibilities specification Guide to responding proportionately to patient safety incidents Patient safety incident response standards Engaging and involving patients, fa...
The leadership and management functions of PSIRF oversight are now much broader and multi-faceted when compared to its predecessors. When implementing and using the PSIRF, trusts should design their oversight systems in a way which evidences improvement rather than compliance. Trusts are encouraged to not only explore what needs to be improved, but...
When designing and maintaining the PSIRF oversight systems and processes, NHSE has outlined six principles which trusts should consider. These are: Use a variety of data Reduce the information collection burden Oversight is not ‘one size fits all’ Capture meaningful insight from patients, families, and staff Metrics require clarity and purpose Bewa...
NHS England has outlined several organisational responsibilities for an effective governance structure. Trust boards should be mindful of the following: Appointment of a PSIRF executive lead: This may be the individual with an overarching responsibility for quality or patient safety, and they must be a member of the board or equivalent leadership t...
There are existing types of incident trigger mandated specific responses; however, the PSIRF does not change the requirements for these. Trusts may find that in some circumstances, learning responses under PSIRF will coincide
A key element of improving the process of learning from PSIs involves external peer review of a sample of learning response reports which have been previously signed off by a trust board. Trusts should outline the proportion of responses that will be externally reviewed and outline the approach within their patient safety incident response policy.
The PSIRF does not mandate investigation as the sole method to produce meaningful learning from PSIs, nor does it prescriptively outline what can and cannot be investigated. Instead, it is a framework which supports the development and maintenance of a patient safety incident response system. This guidance describes what is meant by a system-based ...
Unlike the Serious Incident Framework (SIF), which had a defined threshold for serious incidents, the PSIRF instead focuses on a system-based approach, which involves an examination of the components of a system - including a person(s), tasks, tools and technology, the environment and the wider organisation – to gain a deeper understanding of how t...
The PSIRF supports organisations to respond to PSIs using an approach which will maximise learning and improvement not based on subjective definitions of harm. While some events and issues will arise which will require a special type of response as dictated by policies or regulations (such as the Never Events or learning from deaths criteria), the ...
While full method guides should be reviewed in full within the patient safety incident response toolkit, patient safety incident response activity can be divided into three overarching categories: Learning to inform improvement: Several system-based learning response methods are available for trusts to respond to a PSI. Improvement based on learn...
To ensure that providers meet the minimum expectations of the PSIRF, NHSE has outlined standards for trusts to uphold on: policy, planning and oversight; competence and capacity; engagement and involvement of those affected by patient safety incidents; and proportionate responses. Each of these aspects cover many requirements for trusts, and so whi...
Trusts are required to develop a patient safety incident response policy which describes the systems and processes they have established to facilitate learning and improvement following a PSI. These should create the foundations for effective incident response from the outset. Where patient safety incident response standards are not reached at the ...
Learning response leads, those leading engagement and involvement, as well as those in PSIRF oversight roles, are required to have specific knowledge and experience. Organisations may differ in how they approach engagement and involvement, and this activity may be led by the person leading a learning response, or by a family/staff liaison officer, ...
The engagement and involvement with those affected by PSIs, as outlined within the relevant guidance, should be led by individuals with a specified level of training. All organisations are required to ensure that the Duty of Candour is upheld.
The PSIRF outlines guide timelines for patient safety learning responses and asks for them to begin as soon as possible after the incident is identified. The response methodology outlined in the framework asks that responses are conducted for the sole purpose of learning and identifying improvements that reduce risk and/or prevent or significantly ...
A key element of the PSIRF is that those conducting investigations – as well as those providing oversight – will now be required to have specific knowledge and experience gained through training, including developing knowledge of systems thinking and system-based approaches to learning from PSIs.
To lead to meaningful improvement and learning following a PSI, the PSIRF rightly emphasises the need for robust systems and processes to be established which prioritise a compassionate engagement and involvement approach. This guidance focuses on outlining how organisations can achieve compassionate engagement and involvement through: supporti...
The PSIRF highlights the foundations required for effective and compassionate engagement, including leadership, training and competencies, support systems, ensuring inclusivity, information resources, processes for seeking and acting on feedback, as well as processes for managing dissatisfaction. Additionally, the patient safety incident response s...
The PSIRF details the process of engaging and involving affected individuals and emphasises the importance of treating staff and families seriously as well as with compassion and understanding. When a family or staff member informs an organisation that something has gone wrong, they must be taken seriously from the outset and treated with compassio...
Commenting on the Patient Safety Incident Response Framework, the interim deputy chief executive of NHS Providers, Miriam Deakin said: “Securing better patient safety and outcomes is a top priority for trust leaders and so we welcome this comprehensive framework, which will help ensure that investigation processes and responses by trusts lead to ef...
Commenting on the Patient Safety Incident Response Framework, the interim deputy chief executive of NHS Providers, Miriam Deakin said: “Securing better patient safety and outcomes is a top priority for trust leaders and so we welcome this comprehensive framework, which will help ensure that investigation processes and responses by trusts lead to ef...
Patient safety assessment manual. With later revisions and updates, this WHO-led initiative developed into the Patient Safety Friendly Hospital Framework (PSFHF) to promote patient safety practices in health care facilities as a core element of services provided. The PSFHF
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Rehabilitation services are fundamental in enhancing patients’ functional independence, life participation and play an integral role in maintaining patient flow across the health care continuum. Goal-setting in rehabilitation has long been recommended in organisational and professional guidelines.
Eliminate the need for logins and utilizing WhatsApp as a safety communication channel. E-lia's bite-sized content makes the learning process more effective and easier to retain.
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