Providers of NHS-funded care are required to implement The Patient Safety Incident Response Framework (PSIRF) by Autumn 2023. This replaces the 2015 Serious Incident Framework (SIF) and fundamentally shifts how the NHS responds to patient safety incidents (PSIs).
For further information on the background to PSIRF, please review our recent article.
Under PSIRF, certain categories of incidents require specific responses – these are outlined in Appendix A in NHS England’s “Guide to responding proportionately to patient safety incidents”, part of the raft of supporting documentation and guidance released in conjunction with PSIRF. For example, certain incidents, such as ‘never events’ or where death has occurred (where it is more likely than not a result of problems in care), a locally-led Patient Safety Incident Investigation is required.
However, PSIRF does not seek to prescribe a singular method of investigation or review that must be applied in all cases. PSIRF recognises that NHS organisations have frequently relied upon root cause analysis (RCA) investigations when responding to PSIs. However, NHS England – through PSIRF – endorse a move away from RCA investigations being appropriate in all instances, stating that RCA investigations can be linear in their approach.
Instead, PSIRF suggests the use of various system-based methods in responding to PSIs or a cluster of incidents, according to the type of incident and what will best facilitate learning. The Guidance recommends that these methods are applied where contributory factors with incidents are not well understood, as well as where there is great potential for learning and development. For example:
- Patient Safety Incident Investigation (PSII) – A PSII offers an in-depth review of a single patient safety incident or cluster of incidents to understand what happened and how.
- Multidisciplinary Team (MDT) review – An MDT review supports health and social care teams to learn from patient safety incidents that occurred in the significant past and/or where it is more difficult to obtain staff recollections of events either because of the passage of time or staff availability. The aim is, through open discussion (and other approaches such as observations and walk throughs undertaken in advance of the review meeting(s)), to agree the key contributory factors and system gaps that impact on safe patient care.
- Swarm Huddle – A Swarm Huddle is designed to be initiated as soon as possible after an event and involves an MDT discussion. Staff ‘swarm’ to the site to gather information about what happened and why it happened as quickly as possible and (together with insight gathered from other sources wherever possible) decide what needs to be done to reduce the risk of the same thing happening in future.
- After Action Review (AAR) – AAR is a structured facilitated discussion of an event, the outcome of which gives individuals involved in the event understanding of why the outcome differed from that expected and the learning to assist improvement. AAR generates insight from the various perspectives of the MDT and can be used to discuss both positive outcomes as well as incidents. It is based around four questions:
- What was the expected outcome? / What was expected to happen?
- What was the actual outcome? / What actually happened?
- What was the difference between the expected outcome and the event?
- What is the learning?
With any local review or investigation, PSIRF states that organisations should agree the timeframe for providing any response with those affected by the incident, wherever they are willing and able to be involved in that decision. PSIRF states that a response must start as soon as possible after an incident is identified, and usually be completed within one to three months, but must not take any longer than six months. In exceptional circumstances (e.g. when a partner organisation requests an investigation is paused), a longer timeframe may be needed to respond to an incident.
The Guidance details a number of tools that they have developed in order to assist organisations in deploying the various methods of local investigation and we would strongly encourage that you familiarise yourselves with these.
Hill Dickinson will be continuing to publish articles relating to PSIRF in advance of its implementation. Further, the second in our series of webinars will be taking place on 23 May – we would love to see you there.
For further information related to PSIRF please see our resources or get in touch.
For further information, please contact:
Edward Wrightson, Hill Dickinson
ed.wrightson1@hilldickinson.com
