Patient Safety Incident Response Framework (PSIRF)

Every day more than a million people are treated safely in the NHS. Occasionally, things go wrong, or an unexpected event occurs. These are known as patient safety incidents.

A patient safety incident is any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. These can range from incidents which cause no harm – such as a missed dose of a medicine - to rarer incidents which can have a devastating impact on someone’s life - such as a failure to recognise when someone’s condition is deteriorating.  

Patient Safety Incidents can also include ‘near misses’ where an issue was spotted prior to an incident occurring. A near miss could be when a community nurse notices a patient visit has not been booked so goes ahead and arranges it so it is not delayed; or someone notices a piece of equipment is damaged so removes it before it gets used.

In almost all cases, incidents occur due to problems within the systems people work in, and not because individuals meant to cause any harm.   In the NHS it is important that we learn lessons from Patient Safety Incidents, so that we can try and prevent them from recurring.

The Patient Safety Incident Response Framework (PSIRF), is the new approach to responding to Patient Safety Incidents that occur within organisations contracted to do work for the NHS. It replaces the previous Serious Incidents (SI) Framework (2015). PSIRF will complement the development of a ‘just and learning’ culture at MCH, a culture which encourages learning and ensures compassionate engagement with those affected (patients, families, carers and staff). As part of PSIRF there will be additional patient safety training for all staff so that they can understand how everyone has a role to play within a patient safety culture.

The short video below explains PSIRF:

Introducing the Patient Safety Incident Response Framework (PSIRF): A framework for learning - YouTube

Here at MCH we are developing our Patient Safety Incident Response Plan (PSIRP). In this plan we:

  • identify which patient safety risks worry us most,
  • review how we intend to review Patient Safety Incidents
  • identify learning and
  • maximise the opportunities for improvement.  

We also need to learn to identify when things go well so we can celebrate and replicate them. The plan will accompany internal policies and guidance for staff.