System Safety SIP

A new systems approach to patient safety and learning

In August 2022, NHS England published the new Patient Safety Incident Response Framework (PSIRF) outlining how NHS organisations should respond to patient safety incidents for the purpose of learning and improvement.

The PSIRF supersedes the previous Serious Incident Framework which provided guidance for investigating those incidents where patients suffered serious harm or death. The new framework provides guidance on responses to all patient safety incidents regardless of the level of harm, and represents a significant shift in the way the NHS responds to patient safety incidents.

The PSIRF aims to support significant improvement by introducing several changes as part of four overarching aims:

  • Compassionate engagement and involvement of those affected by patient safety incidents.
  • Application of a range of system-based approaches to learning from patient safety incidents.
  • Considered and proportionate responses to patient safety incidents.
  • Supportive oversight focused on strengthening response system functioning and improvement

The new framework is a major step towards improving safety management across the healthcare system in England and will greatly support the NHS to embed the key principles of a patient safety culture. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals; allowing for more effective learning and improvement, and ultimately making NHS care safer for patients.

Read more about PSIRF on the NHS England website

How we are supporting the region and individual providers

The key ambitions of the System Safety workstream are to

  1. Mobilise effective ICS-level Patient Safety Improvement Networks to deliver the priorities within the NHS Patient Safety Strategy.
  2. Support the national adoption and scale-up of the Patient Safety Incident Response Framework (PSIRF).

Ambition One:

We are engaging with the North East and North Cumbria (NENC) ICS patient safety and quality improvement leads together with provider Patient Safety Specialists, PSIRF implementation teams, and QI leads to codesign a Patient Safety Improvement Network aligned to the ICS footprint. This will build on the current well established regional QI Network and regional PSS group. The Network will provide infrastructure, leadership and coordination to drive safety improvement and deliver an approved Network Improvement plan. The network will set its own patient safety priorities based on local needs.

Details of our Patient Safety Improvement Network can be found on our NENC System Safety space on FutureNHS.

Ambition Two:

We will be guided by the PSIRF Preparation Guide and additional guidance from NHSE  as it is published, in how best to support the ICS and providers with the effective adoption of PSIRF across the region. The aim is to develop an approved ICS level plan for the implementation and scale-up of PSIRF in 2022/23, and for 85% of Trusts to have completed activities relating to phases 1 and 2 of the PSIRF by March 2023 and phases 3-6 by autumn 2023. We will work with the NENC ICS and providers to identify the support they require, provide coaching and improvement support using quality improvement, human factors, and project management methodologies, and coordinate network activities and opportunities to share and learn across the region.

For further information please contact Wendy Halliburton, Patient Safety Lead and Programme Manager for System Safety workstream

Email: [email protected]

Tel: 07561 460871