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Patient Safety Incidence Reporting Framework (PSIRF) Policy
Confidentiality Notice
A. Confidentiality Notice
This document and the information contained therein is the property of Interface Specialist Care Ltd.
This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Interface Specialist Care Ltd.
Patient Safety Incident Response Framework (PSIRF)
1. Introduction
The Patient Safety Incident Response Framework (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.
Patient safety incidents are unintended or unexpected events (including omissions) in care and healthcare that could have or did harm one or more patients/service users. The PSIRF replaces the Serious Incident Framework (SIF; 2015) and represents a significant shift in the way the NHS responds to patient safety incidents.
The PSIRF is not an investigation framework that prescribes what to investigate. Instead, it:
- Advocates a co-ordinated and data-driven approach to patient safety incident response, that prioritises compassionate engagement with those affected by patient safety incidents.
- Embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.
The principles and practices within the PSIRF embody all aspects of the NHS Patient Safety Strategy and wider initiatives under the strategy.
Interface Specialist Care Ltd. is committed to embracing the principles of the Patient Safety Incident Response Framework (PSIRF) to create a safe, transparent, and responsive environment for our patients, service users and staff. Our focus is on ensuring that lessons are learned from incidents and that these lessons result in tangible improvements in our practices and processes.
2. Purpose
This policy provides guidelines for responding to and learning from patient safety incidents maintaining a patient centric and transparent ethic in our handling of incidences.
3. Scope
This policy applies to all staff members, contractors, trainees, observers and volunteers within our organisation. It covers incidents that occur within our facilities or that involve our patients/service users and services.
4. Our Patient Safety Culture
Our organization is dedicated to fostering a culture of patient safety. We prioritise learning from incidents and creating an atmosphere where staff feel comfortable reporting incidents without fear of blame. Promotion of patient safety and a comprehensive, sympathetic and listening response to incidences, and their accurate and candid reporting is an integral part of our training within our service.
5. Cross System / cross pathway / multiagency Incidents and collaboration
For incidents involving multiple organisations, we will work collaboratively with other providers to ensure a coordinated response and shared learning.
6. Openness / Transparency
We adhere to a policy of openness and transparency in all matters related to patient safety incidents. Our commitment is to ensure clear communication and information sharing with patients, families, staff, and other stakeholders. Collaboration is key to improving patient safety, and we will work closely with all relevant parties to ensure coordinated responses to incidents.
7. Process for Responding and Learning from Incidents
When we have a patient safety incident, we will respond by utilising the recommended PSIRF learning response tools. This may include the following, as appropriate:
MDT (Multi-Disciplinary Team)
Is used to gather all relevant professionals together to identify learning from multiple patient safety incidents; agree the key contributory factors and system gaps in patient safety incidents; explore a safety theme, pathway, or process; and gain insight into ‘work as done’ in a health and social care system.
AAR (After Action Review)
Is used when outcomes of an activity or event, have been particularly successful or unsuccessful. It aims to capture learning from these tasks to avoid failure and promote success for the future.
Swarm Huddle
Is used to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk.
PSII (Patient Safety Incident Investigation)
Is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
The national team has a mandated list that they require we use a ‘PSII’ as a learning response for certain types of incidents. The mandated national list is available here https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-3.-Guide-to-responding-proportionately-to-patient-safety-incidents-v1.1.pdf (in Appendix A). Should any of these occur in our organisation we will undertake a PSII as mandated nationally, and we will seek support from our ICB.
8. Governance and Oversight Assurance Process up to Board
Our internal assurance process ensures accountability at all levels of our organisation, up to and including South West London Integrated Care Board (SWL ICB).
Mr. Manu Mehra is responsible for overseeing the incident response process, coordinating investigations, and reporting to the ICB on a regular basis. The Commissioning Team of SWL ICB receives regular updates on incidents, their investigation outcomes, and the actions taken to prevent recurrence. There are regular quality monitoring meetings where data on any incidences is discussed and any actions seen fit decided.
9. Escalation to ICB for Support
We will inform ICB in line with our contractual requirements when an incident occurs as well as contact them if we need support in our learning response to the incident.
10. Staff Training and capacity
We will identify staff who may require incident management related training and utilise the available free NHS training to support.
It is part of our service to set protected time to discuss any incidences or near misses and work as a team to learn from it and minimise risk of similar incidences happening in the future. The minutes of such meetings are recorded.
11. Other Considerations
Addressing health inequalities
From the initial consultation to post treatment aftercare plan, we are respectful of our patient's demographic including race, gender, faith, sexuality, mental capacity compromise and vulnerable dispositions. This is reflected in our patient safety incident report response.
We uphold our duty of candour to our patients.
We liaise with our local safeguarding agencies, the relevant multidisciplinary team and any liaison or key workers to ensure that patient's safety incident response is effective and understood by the patient.
12. Review
This policy will be reviewed as needed in response to significant changes in practice or guidelines.