PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improvement. Our report examines how PSIRF has influenced investigation practices since it was rolled out into all NHS trusts.
Key findings
Key findings from the analysis include:
- 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.
- Staff 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.
- 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.
- Organisational support and informed oversight are fundamental and essential conditions to enable the shift to a system-based approach to investigation with meaningful involvement of those affected.
- 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.
Unique insight
HSSIB has unique insight into PSIRF through our investigation and education activities. We receive direct feedback from hundreds of investigation leads and patient safety specialists who attend our training courses linked to PSIRF and patient safety investigation. HSSIB also has frequent contact with patient safety teams in organisations and we regularly review incident investigation reports as part of our investigation work. In addition, we have used PSIRF tools, templates and guidance in investigations which modelled an approach to investigating under PSIRF.
Opportunities to develop patient safety investigation under PSIRF are suggested for NHS England and for other national and local organisations. The two sets of opportunities are aligned to ensure the most effective development of PSIRF. For example:
- For NHS England: ‘Review and refresh the PSIRF learning response toolkit, to include the use of multimedia guides, to help make the tools and guides easier for investigators to use.
- For local and national organisations: ‘Provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.’
Investigator’s view
Mel Ottewill, Senior Safety Investigator, says: “The process of putting together this report has been positive and encouraging, highlighting how well the Patient Safety Incident Response Framework (PSIRF) has been received across the NHS in England. 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.
“However, the findings also point to the need for a greater focus on implementation and resourcing to ensure PSIRF can reach its full potential. Boards and senior leaders play a critical role in shaping the culture and practice of investigations, their full organisational support is essential to create the conditions needed for PSIRF’s aims to be realised. This report describes ways in which NHS organisations can meaningfully support and enable staff to carry out system-based investigations with those affected by incidents at the heart of that process.”
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