Patient safety

NHS publish new Patient Safety Incident Response Framework

NHS England are giving their patient safety protocols a revamp in the form of the new Patient Safety Incident Response Framework (PSIRF).

The new framework will supplant the Serious Incident Framework from 2015 and will detail how the NHS will develop, maintain and improve the way in which they respond to patient safety emergencies. Any learnings gleaned as a result of the framework will inform future decisions on patient safety.

Aidan Fowler, National Director of Patient Safety at NHS England, said: “The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen – including the factors which contribute to them.“

The framework ultimately supports the establishment of an effective patient safety response system that will run based on four key aims:

  • Ensure those affected by patient safety incidents are engaged with in a compassionate manner.
  • Ensure a range of system-based methods for learning from patient safety incidents are installed.
  • Ensure that all responses to patient safety incidents are considerate and adequate – nothing more and nothing less.
  • Ensure there is sufficient oversight to maintain and improve the response system.

Clinical Vice President for the Royal College of Physicians, Dr John Dean, said: “The introduction of this new framework is a sea change in the way we learn in patient safety. It continues to move us from blame to learning as teams working together.

“We will no longer be just reporting multiple and individual incidents but have the opportunity to truly understand on a local, regional and national level the system factors that increase risk or might result in harm and take preventative action for patients and staff.”

The PSIRF is a contractual obligation under the NHS Standard Contract making its adoption by services provided under that contract like mental health, ambulance, acute and community healthcare providers, mandatory. This also includes maternity and all specialised services.

The new framework will not be compulsory in primary care however – PSIRF can be implemented by primary care providers but NHS England say that “further exploration is required to ensure successful implementation” of the approaches set out in PSIRF work for the primary care sector.

Dr Sean O’Kelly, Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services, Care Quality Commission, said: “We welcome the publication of NHS England’s new Patient Safety Incident Response Framework and the focus it places on effective learning and compassionate, meaningful engagement with those affected when incidents occur.

“Through our monitoring and inspection we have seen how the existence of a strong organisational safety culture, where the views of staff and patients are listened to and acted on, and learning is prioritised is essential to good practice in responding when things go wrong.”

More information about the PSIRF is available here.

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