Since the introduction of the Patient Safety Strategy in 2019, the way we address patient and staff safety has been evolving. The latest change, the introduction of the Patient Safety Incident Response Framework (PSIRF) this autumn, is a significant shift in the way the NHS responds to patient safety incidents. In this article, course leader, and Director of Clinical Governance at Miad Healthcare, Pam Strange, explains the changes and what they mean.

“The new Patient Safety Strategy turned the old approach on its head. The new approach is much more focused on listening to patients, their families, and staff directly involved in an incident and learning how systems need to change. Being proactive and inclusive of more stakeholders is key. Many of the systems we work within need improvement, it’s important that when those changes are made, every voice involved is heard”

Pam Strange, Director of Clinical Governance, Miad Healthcare

Why the change?

The change is a recognition that within the previous Serious Incident Framework, individual incidents were investigated by extremely busy clinicians and managers, perhaps not always leading to the most effective outcomes for patients, staff, and other stakeholders. The new approach allocates trained and dedicated resources to investigations supported by a national arms-length body.

Secondly, the old threshold-based approach for the definition of ‘serious’ meant there was a lot of repetition of similar incidents being investigated. Plus, some incidents that were considered low harm, and were therefore not investigated, could have brought significant improvements to safety outcomes and cost savings. The new approach allows Trusts to tailor investigations in a way that is appropriate to their local context.

Of course, no member of staff wants to be involved in an incident. It takes its toll on patients, family members, staff, and others. By taking a more open and supportive approach, we can give more people a voice with which they can contribute and create better opportunities for learning. The new approach is designed to prioritise support and learning and to diminish the sense that being part of an investigation was a punitive measure.

“Staff, patients, and their families need to work together towards a common goal so that problems are less likely to occur and are less serious when they do. The new framework has a particular focus on involving everyone affected and inviting them to be part of the solution.”

Pam Strange, Director of Clinical Governance, Miad Healthcare

What does it mean for Trusts?

The move to PSIRF is intended to embed a culture of patient safety. The changes are multifaceted, but some of the key changes to the way Trusts investigate incidents are:

• Investigations will be held by those with training as well as dedicated time and resources.
• There are now national standards for patient safety investigations.
• There is a national patient safety syllabus to ensure a professional standard of incident investigation.
• Each Trust will need to identify a Patient Safety Specialist and Patient Safety Incident Investigators.
• The Health Service Safety Investigations Body (HSSIB) has been established with powers to conduct investigations, develop training programmes and oversee the embedding of the process in trusts.

For more details on the new Patient Safety Incident Response Framework, there is a short video on the NHS England website here. (PSIRF)

Support with adopting the new framework

To help Trusts understand and adopt the new framework, Miad Healthcare has designed a new Patient and Staff Safety course. You can see the course outline here. The programme is available as either a face-to-face workshop or live webinar and is fully CPD accredited.

The course, which is also an opportunity for staff to talk about incidents in a safe environment, covers:

• An update on the regulatory framework
• Review the patient safety agenda
• Understanding the patient safety incident response framework (PSIRF)
• Developing an incident risk profile
• Patient safety principles in action
• Human factors and systems thinking
• Never events review

New e-learning module

Plus, for those who would like to arrive at the training course well-prepared, Miad also has a new e-learning module focused on the regulatory change aspects. The e-learning module is interactive and contains real-life examples and quizzes.

To book the Patient Safety Course or e-learning module, please contact the Miad team:

Phone: +44 (0) 1182 287695 or email: info@miadhealthcare.com