Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

We are working on a report to share learning gained from our investigation activities and education programme about patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF).

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 improving patient safety. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health and community healthcare providers.

Our report will look specifically at the adoption of a systems-based approach to investigation and how the experience and involvement of those affected are incorporated within investigation reports.

The report will be based on learning from our regular engagement with NHS staff investigating incidents and review of patient safety incident investigation reports. We will also incorporate learning from our education function that delivers courses to meet the training requirements detailed within PSIRF for staff involved with patient safety incident investigations. The majority of courses are interactive and involve discussion about systems-based patient safety incident investigation under PSIRF.

These investigation and education activities means HSSIB has gathered learning about patient safety incident investigation practice under PSIRF. The purpose of this work is to share that learning via a published report.

The report will be developed working closely with the patient safety team at NHS England, who are responsible for PSIRF. It will provide the opportunity to explore implications for future work by HSSIB and NHS England, to further support NHS organisations to carry out systems-based investigations.

The report will identify areas of good practice and areas of development to help embed systems-based patient safety incident investigations throughout the NHS. The HSSIB education team and HSSIB investigation and insights team will share experiences and insights about the implementation and use of PSIRF investigation tools and guidance in practice.

If you would like to speak to us about this publication before we publish the final report, please email enquiries@hssib.org.uk.