Implementing the new patient safety incident response framework: autumn transition

Replacing the previous Serious Incident Framework, PSIRF or Patient Safety Investigation Framework signifies a shift in how the NHS responds to patient safety incidents. It is designed to promote a more proactive approach to patient safety favouring a “systemic and qualitative investigate methodology” over the previous Root Cause Analysis, After Action Reviews or Multidisciplinary Team Reviews. The PSIRF approach allows for a range of methods to inform improvement beyond investigations recognising that there is no "a one size fits all" approach.

NHS organisations are expected to transition to the new framework by autumn 2023, with adoption mandatory for all services provided under the NHS Standard Contract including NHS funded secondary care provided by independent sector health providers. You can read our earlier blog on PSRIF here.

As part of PSIRF, a PSIRF policy and plan must be developed and signed off by the NHS Trust Board and Integrated Care Board before implementation. While the timeline for transition remains autumn 2023 what transition looks like and when this happens is ultimately a decision made between the provider and their ICB recognising that local health systems are at different stages of implementation. All policies and plans will need to be reviewed every four years.

The expectation is that all organisations are using their PSIRF policy to decide which incidents to investigate based on the learning potential whilst recognising that it can be affected by several factors, including scale and impact, systems and processes to whether the incident has regulatory implications.

An editorial in Psychological Safety on PSIRF suggests that the implementation of PSIRF necessitates the “…development of cultures that foster psychological safety throughout an organisation…allows for a more comprehensive, nuanced understanding of safety incidents and a greater focus on learning and improvement”. Equally relevant to PSIRF is an article by posted on the Patient Safety Learning Hub by Rossanna Hunt who suggests that “ the system-based approach to learning as recommended PSIRF is likely to encourage a ‘just culture’.

PSIRF represents an opportunity for meaningful learning and improved patient safety – so all good reasons to be optimistic.

Get in touch, if you’d like to discuss PSIRF implementation or the interface of PSIRF with your organisation’s duty of candour, inquests and claims.

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