Tracey Herlihey: The Patient Safety Incident Response Framework

Can you tell us who you are and what you do?

My name is Tracey Herlihey, I’m Head of Patient Safety Incident Response Policy within the National Patient Safety Team at NHS England. I work closely with my colleague Lauren Mosley to provide the day-to-day strategic leadership and subject matter expertise for the Patient Safety Incident Response Framework.

Can you give us a brief introduction to PSIRF and why it is important?

The Patient Safety Incident Response Framework (PSIRF) sets out a new approach to achieving effective learning and improvement following patient safety incidents. It aims to embed patient safety incident response within a wider system of improvement prompting a shift towards systematic safety management.

The PSIRF will replace the Serious Incident Framework, with organisations expected to transition to PSIRF from SIF by Autumn 2023.

What are the key improvements between SIF and PSIRF that will have the biggest impact for healthcare professionals and patients?

1. PSIRF prioritises compassionate engagement with those affected by patient safety incidents regardless of whether an organisation conducts a learning response. Compassionate engagement describes an approach that priorities and respects the needs of people who have been affected by a patient safety incident. This may include the Duty of Candour notification or discussion, and actively engaging with patients, families, and healthcare staff to explore support needs, address questions and share experiences of the incident. When an organisation conducts a learning response PSIRF specifies a process of involvement that enables patients, families, and healthcare staff to contribute to the learning response providing support throughout.
2. PSIRF enables organisations to use a range of system based approached to learning from patient safety incidents. Methods that assume simplistic, linear identification of a single cause (i.e., Root Cause Analysis, RCA) are no longer recommended under PSIRF. As such learning responses will look different as they explore complexity and interdependencies between work system components.
3. Proportionality: Importantly, PSIRF removes the term ‘Serious Incident’ and the threshold associated with it. Unlike the SIF, PSIRF is not an investigation framework that specifies what organisations must investigate. Instead, organisations are encouraged to be proportionate in their response to patient safety incidents, basing response decisions on potential for learning and improvement rather than a threshold of ‘seriousness’ or harm. This includes creating a patient safety incident response policy and plan to enable more informed decisions to be made about incident response.
4. Supportive oversight: all healthcare organisations providing and overseeing NHS funded care must work together collaboratively following the oversight mindset principles described in the Oversight roles and responsibilities specification.

What have you learned from the early adopters?

Our early adopters and patient safety partners have been key to informing the design of PSIRF. We have learned a lot from them, much of which is reflected in the documentation published in August 2022, and we continue to learn with them as they embed PSIRF within their organisations. We are forever grateful for their time and support in helping us to continue to shape PSIRF.

An independent evaluation of our early adopter programme found widespread support for PSIRF citing it as ‘a breath of fresh air’ and ‘ a better way forward’. It enabled early adopters to use their resources more effectively and created an openness around investigations that empowered organisations to take local action. The evaluation also revealed that the engagement and planning required to transition to PSIRF is challenging and requires support to enable organisations to transition well. In response to this we have been able to commission our Patient Safety Collaboratives, who have been leading the way enabling providers and their ICBs to come together to share challenges and work through the preparation phases to transition to PSIRF.

I would encourage everyone to get involved by finding out who the PSIRF lead is within their organisation. Any question, please do get in touch with us in the national team at patientsafety.enquiries@nhs.net.

For those starting their PSIRF journey where should begin?

• NHS England
• FutureNHS Workspace
• Introducing the Patient Safety Incident Response Framework (PSIRF): A framework for learning
• Patient Safety Incident Response Framework
• Patient Safety Incident Response Framework: Preparation guide