This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.
It’s winter and healthcare organisations across England are facing a tough time. Increased admissions from flu, long ambulance delays, and even strike action. For many staff it can feel overwhelming, particularly when combined with the fatigue of fighting the Covid-19 pandemic.
The challenge for the NHS with such a myriad of challenges, is to not relegate patient safety learning to a secondary concern.
The new Patient Safety Incident Response Framework (PSIRF) gives both staff and their wider organisations greater freedom to tailor their patient safety incident framework and response plans. This means patient safety learning as well as compassionate engagement with people affected by patient safety incidents can remain centre stage as set out in the PSIRF guidance, Engaging and involving patients, families and staff following a patient safety incident.
As the NHS moves towards the heart of the winter those in oversight roles should develop their understanding of the strengths and weaknesses of their systems and identify any areas that require improvement. This will directly support safety because front line staff, patients, and families are often best placed to identify why things went wrong. Patients and families can help connect the dots, identify the gaps, especially when busy staff may not see the overall picture so clearly.
Therefore, the seven themes set out in the PSIRF guidance will help patient safety leaders ensure the continued and essential involvement of patients and families is maintained even when services are dealing with extreme pressures.
These themes are:
The ask of those in oversight roles is to commit in both words and actions to developing and supporting this area of patient safety. It is important that this work is defined within the context of the setting in which it is going to be delivered. The standards set should be delivered, monitored and expertise developed to ensure standards are maintained and best practice is shared.
Training and professional development is required to ensure those colleagues who have been asked to conduct this role, whether as a dedicated function or as an additional responsibility, are knowledgeable and that a consistent approach is offered. Those that are experienced should share their expertise to assist those who may be newer to the role.
Those affected by a patient safety incident may require support to be involved or support for particular needs that are separate to involvement in the learning response itself. This requires robust and comprehensive knowledge of what support is readily available and what information is accessible to ensure those requiring support can make informed choices about where they may best access or receive the help they require.
Every person affected by a patient safety incident is an individual and should be considered as such. This means not expecting them to fit into an organisational process, but rather the process adapting and adjusting to them. There should be no assumptions that everyone is
able to access online information, read complex documents, understand explanations of process, or be aware of their choices. Time is needed to understand what people’s requirements may be and then ensure that there are robust systems in place to support them.
Information about a patient safety response needs to be accessible, informative and current. For some, written information is a good source of knowledge, but for others this may be hard to grasp. Having choice and considering the needs of the intended audience will ensure no one is disadvantaged.
How do you measure the impact of this work and do you seek feedback from those that are involved? Do you use the views of those previously involved to inform future practice and share organisational learning? Do you seek feedback as you design and develop your systems and do you consider co-production where possible. All of these valuable routes of insight and opinion can help to ensure constant evaluation of process to strive for improvement wherever possible.
If those affected express their dissatisfaction at the practices they have experienced, how do you react? Do you seek to understand why the methods used have failed or have felt disappointing to those affected?
These seven foundations, once explored and established, will assist all those involved to learn, as well as minimise patient safety incidents and drive improvements in safety and quality.