Our approach to responding to patient safety incidents is changing

When things don’t go as planned, it’s really important that we learn from them to make the care we provide as safe as possible.

NHS England has published a Patient Safety Incident Response Framework, which is a major step towards establishing a system that embeds the key principles of a 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.

Alongside the framework, a ‘Guide to engaging and involving patients, families and staff following a patient safety incident’ has been published which 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.

A key aim of the new framework is to allow organisations to focus learning on areas where improvement will have the greatest impact. 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 only incidents meeting the criteria of a ‘serious incident’ are investigated. This enables us to be more focused on working to improve patient safety; and enable us to look at incidents that wouldn’t have met the serious incident criteria but where important learning can still be gained.