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The way we respond to patient safety incidents is changing

Portrait of dentist nurse sitting in office with laptop in her hands looking at camera

Introducing a fundamental shift in the NHS’s approach to responding to patient safety incidents, NHS England has published the new Patient Safety Incident Response Framework (PSIRF).

The framework is a major step towards establishing a safety management system that embeds the key principles of a positive patient safety culture, introducing a focus on understanding how incidents happen, rather than apportioning blame, allowing for more effective learning, and ultimately safer care for patients.

A key aim of PSIRF is to allow organisations to focus learning response resources on areas where improvement will have the greatest impact. Based on their local incident profile and existing improvement work, organisations will identify areas that will benefit most from patient safety incident response, to create their patient safety incident response policy and plan.

PSIRF removes the requirement that all/only incidents meeting the criteria of a ‘serious incident’ are investigated. This enables resources to be focused more effectively on the identified areas with the greatest potential for patient safety improvement; and enable responses to look at incidents that wouldn’t have met the serious incident criteria but where important learning can still be gained.

Published alongside the framework, the ‘Guide to engaging and involving patients, families and staff following a patient safety incident’, also sets out expectations for how those affected by an incident, for example, patients, families, and staff, should be treated with compassion and involved in any investigation process.

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