A report from the Health Services Safety Investigations Body finds that although staff are positive about PSIRF, there needs to be a focus on implementation.
A report from the Health Services Safety Investigations Body (HSSIB) has found that NHS staff have been positive about the impact that the Patient Safety Incident Response Framework (PSIRF) can have on patient safety. It also reveals, however, that more resource and support is needed to ensure PSIRF is implemented consistently across England.
The Patient Safety Incident Response Framework (PSIRF) is a part of the NHS Patient Safety Strategy, which was first published in July 2019. It was created to help healthcare organisations examine serious incidents without fear of inappropriate sanctions. At the same time, it was set up to support those people affected, with the ultimate aim of improving services by focusing on patient safety.
PSIRF has replaced the Serious Incident Framework. Crucially, the PSIRF framework makes no distinction between patient safety incidents and serious incidents. This is not an attempt to gloss over the issue, rather it is an attempt to promote a proportionate approach to responding to patient safety incidents by ensuring that resources allocated to learning are balanced with those needed to deliver improvement.
“The process of putting together this report has been positive and encouraging,” said senior safety investigator Mel Ottewill.
“Staff strongly agree with the shift to a system-based approach to investigation and the need to compassionately engage and involve those affected by incidents, seeing this as not only beneficial but the right thing to do,” she added.
Focus on implementation
The report has found that the shift to a system-based approach to investigation, with greater involvement of those affected by incidents (patients, families and staff), has been positively received by NHS staff.
They value having the flexibility to choose a range of learning responses to patient safety incidents. After-action review is the chosen learning response to many incidents that previously would have triggered an investigation.
But not all findings are positive.
There is variation in the investment organisations have made to implementing PSIRF and its aims, with resulting variation in progress and practice. Greater oversight and support are needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts.
Using system-based tools and involving patients and families in investigations requires particular knowledge and skills, which many staff have not had the opportunity to develop.
“The findings also point to the need for a greater focus on implementation and resourcing to ensure PSIRF can reach its full potential,” said Ottewill.
It is a point backed up by Neil Rowe, head of practice at Maulin Law.
The point of PSIRF, he explains, is to make sure that improvements in patient safety are “not just theoretical but are demonstrable and meaningful in practice”.
