NHS England reported in their July 2026 Patient safety strategy update that PSIRF – the “revolutionary new national approach to incident response and investigation” – is being piloted in over 200 GP practices, with more to come in 2027. The GP pilot demonstrates that PSIRF is not a ‘one-size-fits-all’ approach, writes Rebecca Beaumont, Director of Investigation Services at TMLEP.

 

What is PSIRF?

Patient Safety Incident Response Framework (PSIRF) was launched by NHS England in 2022 as a new framework for responding to patient safety incidents. It replaced the Serious Incident Framework (2015).

The aim of PSIRF is to move away from individual blame and towards understanding why patient safety incidents have occurred and systems-based learning. The four key aims of the framework are:

  1. Compassionate engagement and involvement of those affected by patient safety incidents.
  2. Application of a range of system-based approached to learning from patient safety incidents.
  3. Considered and proportionate responses to patient safety incidents.
  4. Supportive oversight focused on strengthening response system functioning and improvement.

PSIRF does not prescribe methods of investigation and instead promotes a range of learning responses following a patient safety incident, including After Action Reviews, Multidisciplinary Team Reviews, Swarm Huddles, and Patient Safety Incident Investigations. The range of options available to healthcare providers is to encourage a proportionate response to individual incidents depending on the factors involved and the risks and learnings associated with the same.

What have been the learnings from the GP pilot?

PSIRF has been implemented in every NHS secondary care provider since 2024 and part of their standard contract for these providers. The pilot in general practice commenced in 2024 and was led by Health Innovation Network (HIN) South London. 56 organisations were involved in year 1, and this has been expanded to more than 200 GP practices heading into 2027.

The HIN pilot has demonstrated that general practice is operating in a different context to secondary care and a tailored approach to implementation of PSIRF is required. Key differences in general practice highlighted in the year 1 report include:

  • Reporting structures: incident reporting in general practice is managed locally and less embedded in the organisation culture.
  • Resources and capacity: general practice settings have fewer infrastructure resources than secondary care.
  • Learning systems: general practice focuses on learning through discussion rather than formal investigations.

Given these differences, the pilot recognised a need to:

  • Translate PSIRF into the general practice context and language and ensure tools are reflective of this and easily usable by GPs.
  • Identify resource implications for implementation of PSIRF as general practice has less resource allocated to incident investigation than secondary care, likely because far fewer reports of adverse events causing significant harm are initiated in general practice.
  • Recognise and explore the challenges of moving to systems-based thinking in what are smaller organisations, where it can feel less beneficial to take a wider view than to focus on problem solving.

In year 2 of the pilot, these learnings were taken forward. In their report on year 2, participants mostly described the process of implementation of PSIRF as “difficult” or “neutral.” Strong progress was found in the recording of patient safety incidents, but monitoring and patient involvement are still in the early stages of implementation. Infrastructure and resource remain significant barriers with a lack of protected time for staff and a high demand for primary care specific training which is suitable for busy clinical schedules.

The pilot continues and PSIRF is not mandatory for general practice yet. More work is needed to tailor the framework to the general practice context and carve out dedicated resources to facilitate the implementation if PSIRF is to spread.

Team of doctors walking across hospital corridor. Colleagues, doctors team discussing medical case.

What can providers take away from the PSIRF GP pilot?

The GP pilot for PSIRF highlights that the framework is not ‘one-size-fits-all’ and needs to be tailored to the individual organisational context when being used. Secondary care providers should be equally cognisant of this in their own approach to PSIRF, even where the framework is established within their organisation.

PSIRF users should ensure their approach is regularly audited by:

  • Assessing the tools being used to implement PSIRF and ensuring their continued suitability.
  • Engaging with staff to ensure that training is fit for purpose and they have capacity to comfortably engage with PSIRF as part of their practice.
  • Adapting and updating procedure and process associated with PSIRF according to organisational context.

The roll-out of PSIRF across different providers is a welcome development in moving away from a blame culture in incident investigation and towards compassionate systems-based learning. The challenge is ensuring frameworks work for providers who have disparate resources, organisational structure, and clinical practice. PSIRF is supposed to be flexible, and providers who embrace this will see more of its benefit.

TMLEP’s investigations team are regularly engaged to assist providers with this kind of gap analysis – for example, where policies have fallen short and providers need to understand the why, how, and what in order that they can prevent recurrence of issues.

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