All these documents can be accessed through the Patient Safety Incident Response Framework (PSIRF) document and supporting guidance on the NHS England website. We have repeated links to the main documents here, with a brief summary of what each document covers. For ease of access, there are also links to associated documents referred to in each. Please note that all of the main PSIRF documents regularly cross-refer to each other and are very much interrelated.
Patient Safety Incident Response Framework (PSIRF)
The key document providing an overview of what PSIRF is, which organisations it affects, and how it should be implemented. As well as the key documents listed below, it refers to the following:
- NHS Patient Safety Strategy
- Patient safety specialists
- Patient safety syllabus
- Framework for involving patients in patient safety
- Learn From Patient Safety Events service
- NHS long term plan
- Patient safety learning response toolkit (sub links below in serial 3)
Engaging and involving patients, families and staff following a patient safety incident
The PSIRF supports development of a patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents. This document is supporting guidance on engaging and involving patients, families and staff following a patient safety incident. It also refers to the following:
- Being open (NRLS)
- Duty of candour (CQC)
- Second victim support[1]
- Support for staff following patient safety incidents (HSIB)
- Learn together (NIHR) Involvement guidance[2]
- How to make a good apology (SPSO)
- Saying sorry (NHS Resolution)
- NHS Just culture guide
Guide to responding proportionately to patient safety incidents
PSIRF is not an investigation framework: it does not mandate investigation as the only method for learning from patient safety incidents or prescribe what to investigate. This guide describes what is meant by a system-based approach to learning and taking a proportionate approach in a patient safety incident response, and how to achieve these aims through patient safety incident response planning. It should be used alongside the PSIRF policy and plan templates (also listed in their own section below). This guide also refers to:
- Patient safety learning response toolkit[3]
- Never events (2018 policy and framework, and never events list)
- Learning from deaths in the NHS
Oversight roles and responsibilities specification
This describes the oversight mindset and approaches, along with organisational responsibilities that should be considered within PSIRF. It emphasises that providers, regulators, and Integrated Care Boards should design systems to demonstrate improvement, rather than compliance with prescriptive measures. Oversight under PSIRF focuses on engagement and empowerment, rather than the more traditional command and control. This also refers to:
- A framework for measuring and monitoring safety (A practical guide to using a new framework for measuring and monitoring safety in the NHS- The Health Foundation 2014)
Patient safety incident response standards
Provides the complete list of patient safety incident response standards, and where relevant refers to specific PSIRF documentation. Organisations are expected to uphold the standards to ensure they meet the minimum expectations of the PSIRF. These standards cover the following aspects of PSIRF:
- policy, planning and oversight
- competence and capacity
- engagement and involvement of those affected by patient safety incidents
- proportionate responses
The document also refers to:
Patient Safety Incident Response Framework – Preparation guide
This guide describes the preparation phases that need to be worked through to implement PSIRF. It was developed from early adopters’ insight. It summarises the organisation roles and requirements for providers, Integrated Care Boards, NHS Regions, Patient Safety Collaboratives, and the NHS National team. The guide also refers to:
Patient Safety Incident Response Policy and Plan templates
These are templates to guide organisations through the development of their patient safety incident response policy and plan. The policy relates to the organisation’s approach to developing and maintaining systems and processes for responding to patient safety incidents. It highlights the four aims of PSIRF (see overview). The plan sets out how the organisation intends to respond to patient safety incidents over a period of 12 to 18 months.
[1] Second victims are healthcare employees who are involved in an unanticipated adverse patient event, a medical error and/or a patient-related injury and become victimized in the sense that the employee is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have let the patient down, second-guessing their clinical skills and knowledge base. The impact may be personal and/or professional.
[2] Includes: • Investigator guidance (supports investigators to involve patients, families, and staff in learning responses) • Patient and family information booklet (informs the patient and their family about how to get involved in learning response) • Staff information booklet (informs staff about how to get involved in learning response) • Investigation record (supports and prompts investigators to undertake specific involvement activity in individual investigations).
[3] The patient safety learning response toolkit includes: Patient safety incident investigation report template; Introduction to SEIPS; Preparing to respond; Learning response methods; Exploring everyday work; Responding to broad patient safety issues; Synthesis; Developing safety actions