August 19, 2022

New framework for patient safety investigations launched by NHS England

I follow closely the commitments made by NHS England in the field of patient safety. In its 2021 patient safety strategy update, the NHS made a commitment to implement a new guidance on how NHS organisations respond to patient safety incidents. A key part of that strategy was to try and simplify the complexity of the NHS, particularly with respect to patient safety.

In an encouraging step, on 16 August 2022, NHS England published the new Patient Safety Incident Response Framework (PSIRF). This replaces the Serious Incident Framework published in 2015, which had been criticised for creating blame-seeking based investigations and limiting opportunities for candour and transparency.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

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

In response to the new framework, the Healthcare Safety Investigation Branch (HSIB), who are an independent body who are dedicated to improving patient safety through independent investigations, has said:

PSIRF is a major step towards improving safety management across the healthcare system in England. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals – a fundamental principal of HSIB investigations. This will allow for more effective learning and improvement, and ultimately make NHS care safer for patients.”

Having read accounts from the patient safety investigators on the ground, who have already trialled the new framework, it sounds very encouraging. They agree that there is a real commitment to engage in all relevant parties throughout the investigation, including the patient and families to ensure buy-in and transparency. The approach to seeking input from staff involved in the incident has changed, with productive discussions and a focus on the learning principles, as opposed to seeking out personal blame.

NHS England has committed to work with the Healthcare Safety Investigation Branch (HSIB) in the testing and introduction of this new framework. The implementation of this new framework cannot take place overnight, of course, as it comes with a whole new set of systems and processes for NHS organisations to adopt. So there is now a transition phase in which NHS organisations will need to adopt the new framework over the course of the next 12 months, with support and training from NHS England.

The new framework demonstrates a commitment by the NHS to increase the scale and pace in tackling patient safety concerns and I believe the new framework will lead to better learning outcomes and change when something does go wrong.

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