# data[].attributes.headline
The PSIRF Learning Response Tools: snapshot survey report. July 2024. Judy Walker Associates Ltd.

# data[].attributes.subject
The PSIRF Learning Response Tools: snapshot survey report. July 2024. Judy Walker Associates Ltd.

# data[].attributes.attachment_link.title
PSIRF LRTs Snapshot Survey Full Results July 2024

# data[].attributes.headline
Pressure Ulcer After Action Review (AAR) template

# data[].attributes.subject
Pressure Ulcer After Action Review (AAR) template

# data[].attributes.body
West Suffolk NHS Foundation Trust

# data[].attributes.headline
University Hospitals Southampton NHS Foundation Trust. Application of SEIPS and AcciMAP to an incident.

# data[].attributes.subject
University Hospitals Southampton NHS Foundation Trust. Application of SEIPS and AcciMAP to an incident.

# data[].attributes.headline
Fatigue Risk Management Strategy for Newcastle Hospitals 2024

# data[].attributes.subject
Fatigue Risk Management Strategy for Newcastle Hospitals 2024

# data[].attributes.headline
PSIRF: Key Messages For Patients, Families, Carers & Workforce.

# data[].attributes.subject
PSIRF: Key Messages For Patients, Families, Carers & Workforce.

# data[].attributes.attachment_link.readable_text
Scottish Patient Safety Programme

The Scottish Patient Safety Programme (SPSP), part of the ihub, is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered.

# data[].attributes.attachment_link.description
Scotland's Improvement Hub (ihub) helps organisations redesign and continuously improve their health and social care to meet the changing needs of the people using these services.

# data[].attributes.attachment_link.readable_text
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.

Aidan Fowler, National Director of Patient Safety, NHS England - "The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen - including the factors which contribute to them."

Contents

Rt Hon Jeremy Hunt, MP - "The new Patient Safety Incident Response Framework is very welcome. It is great to see the involvement of those affected by patient safety incidents at its heart and the emphasis on learning and improvement are vital if we are to reduce avoidable harm across the NHS."

A new approach to responding to patient safety incidents

The PSIRF will replace the current Serious Incident Framework (2015).

The framework represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. It is a key part of the NHS patient safety strategy.

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

1. Compassionate engagement and involvement of those affected by patient safety incidents

2. Application of a range of system-based approached to learning from patient safety incidents

3. Considered and proportionate responses to patient safety incidents

4. Supportive oversight focused on strengthening response system functioning and improvement

Who does PSIRF apply to?

The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Primary care providers may also wish to adopt PSIRF, but it is not a requirement at this stage. Further exploration is required to ensure successful implementation of the PSIRF approaches within primary care.

Dr Sean O'Kelly, Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services, Care Quality Commission - "We welcome the publication of NHS England's new Patient Safety Incident Response Framework (PSIRF) and the focus it places on effective learning and compassionate, meaningful engagement with those affected when incidents occur. Through our monitoring and inspection we have seen how the existence of a strong organisational safety culture, where the views of staff and patients are listened to and acted on, and learning is prioritised is essential to good practice in responding when things go wrong."

Saffron Cordery, Interim Chief Executive, NHS Providers - "We welcome this framework as a key tool to ensure that investigation processes and responses by trusts lead to effective learning and improvement, contributing to better patient safety and outcomes - the top priority of trust leaders."

PSIRF podcasts

We are continuing to record a series of podcasts to help introduce PSIRF and support providers to prepare for its implementation. Links to these podcasts are listed below, in chronological order from newest to oldest:

Early adopters share their experiences

In the videos below early adopters describe their experience of implementing PSIRF

Lucy Winstanley, Head of Patient Safety and Quality, West Suffolk NHS Foundation Trust

Megan Pontin, Patient Safety Incident Investigator, West Suffolk NHS Foundation Trust

Saranna Burges, Director for Patent Safety and Quality, Norfolk and Suffolk NHS Foundation Trust

Lisa Falconer, Head of Clinical Quality and Patient Safety, NHS Derby and Derbyshire ICB

Preparing for PSIRF

Implementation of PSIRF will not be achieved by a change in policy alone, and it cannot be implemented in days or weeks as it requires work to design a new set of systems and processes. To help organisations prepare to transition to PSIRF we have developed a preparation guide to support those leading PSIRF implementation across the NHS.

Organisations are expected to transition to PSIRF within 12 months of its publication, and transition should be completed by Autumn 2023. The preparation guide breaks PSIRF preparation into six phases to ease transition and provide detail around discrete activities that will set strong foundations for implementing the framework.

Dr Rosie Benneyworth, Interim Chief Investigator at the Healthcare Safety Investigation Branch (HSIB) - "We welcome the publication of the Patient Safety Incident Response Framework (PSIRF), a significant development in the patient safety landscape in England. PSIRF reflects the key principle that guides our national patient safety investigations - a focus on understanding how incidents happen rather than attributing blame or liability - and applies this to local investigations. As well as co-authoring the supporting guidance around involving patients, families and staff, HSIB has developed a range of training courses to help NHS trusts put PSIRF into practice."

Supporting documents

The PSIRF is supported by further detail provided in four guidance documents:

Engaging and involving patients, families and staff following a patient safety incident

Guide to responding proportionately to patient safety incidents

Oversight roles and responsibilities specification

Patient safety incident response standards

We have also produced templates to guide organisations through the development of their patient safety incident response policy and patient safety incident response plan

Engaging and involving patients, families and staff following a patient safety incident

Compassionate engagement and involvement of those affected by patient safety incidents is central to PSIRF.

Please visit our Engaging and involving patients, families and staff following a patient safety incident webpage for further information.

Learning response toolkit

The PSIRF promotes a range of system-based approaches for learning from patient safety incidents. Organisations are encouraged to use the national tools and guides available in our learning response toolkit.

The national tools have been developed in collaboration with human factors experts and the Healthcare Safety Investigation Branch, who lead the way in modern healthcare safety investigation methodology. They have been tested with representative end users whose feedback has been instrumental in informing the design.

We will continue to review and evaluate the design of the Patient Safety Incident Investigation report template.

If you would like to provide feedback, please contact patientsafety.enquiries@nhs.net

Join our PSIRF FutureNHS workspace

Further resources (including webinars, podcasts and additional tools) to support providers to prepare, transition and work under PSIRF will be made available throughout 22/23 via our PSIRF FutureNHS workspace. This workspace is part of the NHS Patient Safety workspace

We will also use this workspace to communicate with staff and local stakeholders via the message board. This workspace is available for anyone to join (you don't need an NHS email). If you're not a member and would like to join please email NHSps-manager@future.nhs.uk.

Upcoming PSIRF webinars

To continue to support organisations as PSIRF goes live, we are hosting a further series of webinars up to September 2024, to share experiences and learnings as the framework is operationalised.

Register via the links below:

Developing PSIRF

Reports by the Public Administration Select Committee in March 2015; the Government's response in July 2015; the Parliamentary and Health Service Ombudsman's report in December 2015; the CQC's report in June 2016, and the CQC's report in Dec 2016 all identified shortcomings in the way patient safety incidents are investigated and learned from.

In response to these reports, in 2018 we conducted a widespread engagement exercise around the future of NHS patient safety investigation to gather thoughts and feedback to support us to develop the PSIRF to replace the existing Serious Incident Framework.

The PSIRF was developed based on the feedback received through our The future of NHS patient safety investigation engagement activity.

Published in March 2020 the Introductory PSIRF was tested by 24 early adopters (including 17 provider organisations alongside their commissioners and regional leads) for two years. The early adopter programme was independently evaluated and alongside feedback from our early adopters has informed the development of the PSIRF (2022).

The evaluation report is available on our FutureNHS workspace.

List of early adopters

Listed by region, we would like to thank the following early adopter organisations that have been instrumental in the development of the final version of the PSIRF:

East

Norfolk and Suffolk NHS Foundation Trust

East Suffolk and North Essex NHS Foundation Trust

Essex Partnership University Foundation Trust

West Suffolk NHS Foundation Trust

NHS Suffolk and North East Essex ICS

London

London Ambulance Service NHS Trust

North West London Collaboration of ICSs

Midlands

Chesterfield Royal Hospital NHS Foundation Trust

Derbyshire Community Health Services NHS Foundation Trust

Derbyshire Healthcare NHS Foundation Trust

Derbyshire Health United

University Hospital Derby and Burton NHS Foundation Trust

NHS Derby and Derbyshire ICS

National

Care UK (Independent provider of healthcare in prisons)

North East and Yorkshire

Leeds Teaching Hospitals NHS Trust

NHS Leeds ICS

North West

East Lancashire Hospitals NHS Trust

NHS East Lancashire

South East

Isle of Wight NHS Trust

NHS Isle of Wight

South West

Cornwall Partnership NHS Foundation Trust

North Bristol NHS Trust

Royal Cornwall Hospitals NHS Trust

NHS Kernow

Get in touch

If you would like to get in touch, please contact Patientsafety.enquiries@nhs.net.

Alternatively, you can use the PSIRF discussion board on our FutureNHS platform.

# data[].attributes.attachment_link.title
Patient Safety Incident Response Framework

# data[].attributes.attachment_link.description
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.

# data[].attributes.headline
Healthcare Services Safety Investigations Body:

# data[].attributes.subject
Healthcare Services Safety Investigations Body:

# data[].attributes.attachment_link.title
Health Services Safety Investigations Body (HSSIB)

# data[].attributes.attachment_link.description
We investigate patient safety concerns across England to improve NHS care at a national level.

# data[].attributes.attachment_link.description
Welcome to the Improvement Academy We are a team of improvement scientists, patient safety experts and clinicians who are committed to working with frontline services, patients and the public to deliver real and lasting change. We adopt a theory-based approach to improvement that's practical, tried and tested.

# data[].attributes.headline
Introducing after action review (AAR) within services: guidance for service managers. Health Service Executive (HSE) Quality and Patient Safety Directorate. 

# data[].attributes.subject
Introducing after action review (AAR) within services: guidance for service managers. Health Service Executive (HSE) Quality and Patient Safety Directorate. 

# data[].attributes.headline
Learning Response Review and Improvement Tool

# data[].attributes.subject
Learning Response Review and Improvement Tool

# data[].attributes.headline
Essex Partnership University NHS Foundation Trust PSIRP

# data[].attributes.subject
Essex Partnership University NHS Foundation Trust PSIRP

# data[].attributes.headline
Four PSIRF learning response tools summarised

# data[].attributes.subject
Four PSIRF learning response tools summarised

# data[].attributes.headline
North West Ambulance Service NHS Trust. PSIRP. 

# data[].attributes.subject
North West Ambulance Service NHS Trust. PSIRP. 

# data[].attributes.headline
Standard Operating Procedure (SOP) PSIRF ICB sign off process for smaller independent providers

# data[].attributes.subject
Standard Operating Procedure (SOP) PSIRF ICB sign off process for smaller independent providers

# data[].attributes.body
February 2023

# data[].attributes.attachment_link.title
Walkthrough of CQC's new regulatory approach

# data[].attributes.attachment_link.readable_text
Our assessment framework is built on our five key questions and well-known ratings system and is what we use to set out our view of quality and make judgements.

We will start to introduce it in phases and be clear when it will directly affect health and care providers. We are publishing our new framework now so that providers and other stakeholders can start to become familiar with it.

From today, 18 July 2022, providers and others will be able to read more about our quality statements and evidence categories. We'll build on this with more detail about how it will work in practice over the coming weeks and months. For example, information on the evidence we'll require in our assessments of each service type and what our assessments will look like.

Why we're changing

There are three main reasons why we need to change:

We need to make things simpler so we can focus on what really matters to people.

We need to better reflect how care is actually delivered by different types of service as well as across a local area.

We need one framework that connects our registration activity to our assessments of quality.

What's different

We've already confirmed that our quality ratings and five key questions will stay central to our approach. But we're replacing our existing key lines of enquiry (KLOEs) and prompts with new 'quality statements'. These will reduce the duplication that's in our four current separate assessment frameworks to allow us to focus on specific topic areas under each key question, and will link to the relevant regulations to make it easier for providers.

We call the quality statements 'we statements' as they're written from a provider's perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. We wanted to maintain that ethos when developing our assessment framework.

Importantly, we'll base our assessments of quality in all types of services, and at all levels, on this single assessment framework. For local authorities and integrated care systems, we will use a subset of the quality statements being published today.

To make our judgements more structured and consistent, we have also developed six categories for the evidence we collect:

people's experiences

feedback from staff and leaders

observations of care

feedback from partners

processes

outcomes of care.

We want to be clearer with providers and the public about how we use the information we have about care in a service or local area. So, for each quality statement we'll state which evidence we will always need to collect and look at. This will vary depending on the type of service. For example, the evidence we can collect for GP practices will be different to what we'll have available when assessing a home care service. It will also depend on the level at which we're assessing. For example, the evidence we have when a new service is registering for the first time will be different from a service that has been operating for a while.

To fulfil the ambitions in our strategy, the assessment framework emphasises the need to create cultures that learn and improve, and we set expectations for how services and providers need to work together, and within systems, to plan and deliver safe, person-centred care.

Building on strong engagement

We've developed our new assessment framework following almost nine months of engagement and thousands of interactions with providers, people who use services and other stakeholders.

Feedback told us that stakeholders support the simplicity of our new framework. Having just 34 topic areas across the five key questions means that providers will be much clearer about what we're looking for in our assessments.

Although people valued the simplicity of the approach, many felt the language was too complex. In response, we carried out some user research and have reviewed the wording of the quality statements to make them easier to read.

As a result of our engagement with providers, we've also created some guidance that shows examples of the evidence we collect for each category.

# data[].attributes.attachment_link.description
Our assessment framework is built on our five key questions and well-known ratings system and is what we use to set out our view of quality and make judgements. We will start to introduce it in phases and be clear when it will directly affect health and care providers.

# data[].attributes.attachment_link.title
Second Victim - Second victims are healthcare employees who are involved in an unanticipated adverse patient event, a medical error and/or a patient-related injury and become victimized in the sense that the employee is traumatized by the event.

# data[].attributes.attachment_link.description
Copyright Bradford Teaching Hospitals Foundation NHS Trust. All rights reserved. Permission should be sought prior to amending any resource from this or other pages contained in this site. This website should always be acknowledged as the source of these resources when they are used.

# data[].attributes.attachment_link.readable_text
This programme is in partnership with...

NHS Patient Safety Syllabus training programme

When patients are harmed, it has an impact on them, their loved ones, our staff, and others who work in the healthcare system. It is crucial that all staff, whatever our roles, see safety not just as our collective responsibility, but as a key priority. We all need to think differently about what patient safety means and how we can make improvements.

Overall, we can make healthcare even safer by:

Dealing with risks before they can cause harm

Working to create a positive patient safety culture

Building safer systems

Recognising everyone's role in patient safety

For details of how to access the programme please scroll down to the 'How to Access' section.

More information

The NHS Patient Safety Strategy will help us deliver the changes we need. The Strategy includes a patient safety syllabus and training programme for the whole NHS. This is designed to help everyone who works in the NHS take all the necessary steps to ensure our patients are safe while they are in our care.

This training has five levels, which build on each other, please click on the boxes below to find information about each level.

Level one - Essentials for patient safety

Level one - Essentials for patient safety

Level One - Essentials for Patient Safety (estimated completion time 30mins)
Is the starting point for all NHS staff, and includes sections on:

Listening to patients and raising concerns

The systems approach to safety, where instead of focusing on the performance of individual members of staff, we try to improve the way we work

Avoiding inappropriate blame when things don't go well

Creating a just culture that prioritises safety and is open to learning about risk and safety

There is no skills assessments in Levels 1 although a certificate of completion will be received.

Level one - Essentials of patient safety for boards and senior leadership teams

Level one - Essentials of patient safety for boards and senior leadership teams

Level One - Essentials for Patient Safety for Boards and senior leadership teams (estimated completion time 30mins)
Additional session for senior leaders and executive teams, covering:

The human, organisational and financial costs of patient safety

The benefits of a framework for governance in patient safety

Understanding the need for proactive safety management and a focus on risk in addition to past harm

Key factors in leadership for patient safety

The harmful effects of safety incidents on staff at all levels

There is no skills assessments in Levels 1 although a certificate of completion will be received.

Level two - Access to practice

Level two - Access to practice

Level two - Access to Practice (estimated completion time 45mins)
Access to practice is intended for all clinical and non-clinical staff who have an interest in understanding more about patient safety or who want to go on to access the higher levels of training. There are two sessions:

The first introduces systems thinking (how the way we work can be used to reduce error and improve safety) and risk expertise (how we can identify and manage risk to keep patients safe).

The second session looks at human factors (the science of work and of working together in safely designed systems) and safety culture (the significance of a true learning culture, free of inappropriate blame).

Level two Access to Practice includes an assessment, which on completion staff will receive a certificate and will have access to the sector specific sessions covering Mental Health, Primary Care, Maternity Care, Acute Care, and Management and Administration.

Level two - Sector Specific Sessions

Level two - Sector Specific Sessions

Level two - Sector Specific sessions (Accessible following completion of Level two Access to Practice)
On completion of Level 2 Access to Practice all staff will have access to five patient safety sector specific sessions covering good practice, human factors, risk management, systems thinking, and safety culture. Each of these sessions can be completed by individuals or used as part of a group discussion. These sessions aim to highlight the learning from Level 2 - Access to Practice. The sessions cover:

Mental Health

Primary Care

Acute Care

Maternity Care

Management and Administration

A certificate of completion is available following completion of each session.

Levels three to five

Levels three to five
Levels 3-5 are in development and expected to be available from Autumn 2023.

Acknowledgements

Acknowledgements of assistance developing the training modules

We would like to acknowledge those who have helped review these training modules as they were developed. This included members of key stakeholder organisations and over 50 frontline clinical staff.

We would like to acknowledge the support and guidance offered by members of the following organisations represented on our Advisory Group for development of the syllabus.

Allied Health Professions Federation

Academic Health Science Network

Care Quality Commission

Council of Postgraduate Medical Deans

Council of Deans of Health

Department of Health Northern Ireland

General Medical Council

Heath and Care Professions Council

Healthcare Safety Investigation Branch

Health Education England

Health Education and Improvement Wales

Lay representatives

Medical Schools' Council

National Association of Clinical Tutors

NHS Clinical Commissioners

NHS Education for Scotland

NHS Employers

NHS England and Improvement

Nursing and Midwifery Council

Royal College of General Practitioners

Royal College of Midwives

Royal College of Nursing

Royal College of Physicians including its Chief Registrar Programme

Royal Pharmaceutical Society

Society & College of Radiographers

UK Foundation Programme

Patient Safety Development Team

How to Access

In order to access any elfh programme, you will need an elfh account. If you do not have one, then you can register by selecting the Register button below.
Register >
To view the NHS Patient Safety Syllabus training programme, select the View button below. If you already have an account with elfh, you will also be able to login and enrol on the programme from the View button.
View >
If you already have an account with elfh, then you can enrol on to the NHS Patient Safety Syllabus training programme by logging in to the elfh Hub, selecting My Account > Enrolment and selecting the programme. You can then access the programme immediately in the My e-Learning section.

NHS healthcare staff in England - ESR

The NHS Patient Safety Syllabus training programme is also available to NHS healthcare staff via the Electronic Staff Record (ESR). Accessing this e-learning via ESR means that your completions will transfer with you throughout your NHS career.

Further details are available here.

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the NHS Patient Safety Syllabus training programme, please contact elfh directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact elfh directly to express interest.

More information

Please select the following link for more information on how to use the elfh Hub.

elfh is a NHS England programme in partnership with the NHS and professional bodies

© elearning for healthcare 2023

# data[].attributes.attachment_link.title
NHS Patient Safety Syllabus training - elearning for healthcare

# data[].attributes.attachment_link.description
Safer culture, safer systems, safer patients

# data[].attributes.attachment_link.description
We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

# data[].attributes.attachment_link.authors[].name
Chartered Institute of Ergonomics & Human Factors

# data[].attributes.attachment_link.description
Enrol on an HSIB investigation education course. We offer professional healthcare safety investigation training to the NHS in England.

# data[].attributes.attachment_link.description
About the project Patient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.

# data[].attributes.attachment_link.readable_text
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.

Aidan Fowler, National Director of Patient Safety, NHS England - "The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen - including the factors which contribute to them."

Contents

Rt Hon Jeremy Hunt, MP - "The new Patient Safety Incident Response Framework is very welcome. It is great to see the involvement of those affected by patient safety incidents at its heart and the emphasis on learning and improvement are vital if we are to reduce avoidable harm across the NHS."

A new approach to responding to patient safety incidents

The PSIRF will replace the current Serious Incident Framework (2015).

The framework represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. It is a key part of the NHS patient safety strategy.

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

1. Compassionate engagement and involvement of those affected by patient safety incidents

2. Application of a range of system-based approached to learning from patient safety incidents

3. Considered and proportionate responses to patient safety incidents

4. Supportive oversight focused on strengthening response system functioning and improvement

Who does PSIRF apply to?

The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Primary care providers may also wish to adopt PSIRF, but it is not a requirement at this stage. Further exploration is required to ensure successful implementation of the PSIRF approaches within primary care.

Dr Sean O'Kelly, Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services, Care Quality Commission - "We welcome the publication of NHS England's new Patient Safety Incident Response Framework (PSIRF) and the focus it places on effective learning and compassionate, meaningful engagement with those affected when incidents occur. Through our monitoring and inspection we have seen how the existence of a strong organisational safety culture, where the views of staff and patients are listened to and acted on, and learning is prioritised is essential to good practice in responding when things go wrong."

Saffron Cordery, Interim Chief Executive, NHS Providers - "We welcome this framework as a key tool to ensure that investigation processes and responses by trusts lead to effective learning and improvement, contributing to better patient safety and outcomes - the top priority of trust leaders."

PSIRF podcasts

We are continuing to record a series of podcasts to help introduce PSIRF and support providers to prepare for its implementation. Links to these podcasts are listed below, in chronological order from newest to oldest:

Early adopters share their experiences

In the videos below early adopters describe their experience of implementing PSIRF

Lucy Winstanley, Head of Patient Safety and Quality, West Suffolk NHS Foundation Trust

Megan Pontin, Patient Safety Incident Investigator, West Suffolk NHS Foundation Trust

Saranna Burges, Director for Patent Safety and Quality, Norfolk and Suffolk NHS Foundation Trust

Lisa Falconer, Head of Clinical Quality and Patient Safety, NHS Derby and Derbyshire ICB

Preparing for PSIRF

Implementation of PSIRF will not be achieved by a change in policy alone, and it cannot be implemented in days or weeks as it requires work to design a new set of systems and processes. To help organisations prepare to transition to PSIRF we have developed a preparation guide to support those leading PSIRF implementation across the NHS.

Organisations are expected to transition to PSIRF within 12 months of its publication, and transition should be completed by Autumn 2023. The preparation guide breaks PSIRF preparation into six phases to ease transition and provide detail around discrete activities that will set strong foundations for implementing the framework.

Dr Rosie Benneyworth, Interim Chief Investigator at the Healthcare Safety Investigation Branch (HSIB) - "We welcome the publication of the Patient Safety Incident Response Framework (PSIRF), a significant development in the patient safety landscape in England. PSIRF reflects the key principle that guides our national patient safety investigations - a focus on understanding how incidents happen rather than attributing blame or liability - and applies this to local investigations. As well as co-authoring the supporting guidance around involving patients, families and staff, HSIB has developed a range of training courses to help NHS trusts put PSIRF into practice."

Supporting documents

The PSIRF is supported by further detail provided in four guidance documents:

Engaging and involving patients, families and staff following a patient safety incident

Guide to responding proportionately to patient safety incidents

Oversight roles and responsibilities specification

Patient safety incident response standards

We have also produced templates to guide organisations through the development of their patient safety incident response policy and patient safety incident response plan

Engaging and involving patients, families and staff following a patient safety incident

Compassionate engagement and involvement of those affected by patient safety incidents is central to PSIRF.

Please visit our Engaging and involving patients, families and staff following a patient safety incident webpage for further information.

Learning response toolkit

The PSIRF promotes a range of system-based approaches for learning from patient safety incidents. Organisations are encouraged to use the national tools and guides available in our learning response toolkit.

The national tools have been developed in collaboration with human factors experts and the Healthcare Safety Investigation Branch, who lead the way in modern healthcare safety investigation methodology. They have been tested with representative end users whose feedback has been instrumental in informing the design.

We will continue to review and evaluate the design of the Patient Safety Incident Investigation report template.

If you would like to provide feedback, please contact patientsafety.enquiries@nhs.net

Join our PSIRF FutureNHS workspace

Further resources (including webinars, podcasts and additional tools) to support providers to prepare, transition and work under PSIRF will be made available throughout 22/23 via our PSIRF FutureNHS workspace. This workspace is part of the NHS Patient Safety workspace

We will also use this workspace to communicate with staff and local stakeholders via the message board. This workspace is available for anyone to join (you don't need an NHS email). If you're not a member and would like to join please email NHSps-manager@future.nhs.uk.

Upcoming PSIRF webinars

To support organisations to prepare to transition to PSIRF we are hosting a series of webinars.

We will add details of further events across 2023/24 soon.

Developing PSIRF

Reports by the Public Administration Select Committee in March 2015; the Government's response in July 2015; the Parliamentary and Health Service Ombudsman's report in December 2015; the CQC's report in June 2016, and the CQC's report in Dec 2016 all identified shortcomings in the way patient safety incidents are investigated and learned from.

In response to these reports, in 2018 we conducted a widespread engagement exercise around the future of NHS patient safety investigation to gather thoughts and feedback to support us to develop the PSIRF to replace the existing Serious Incident Framework.

The PSIRF was developed based on the feedback received through our The future of NHS patient safety investigation engagement activity.

Published in March 2020 the Introductory PSIRF was tested by 24 early adopters (including 17 provider organisations alongside their commissioners and regional leads) for two years. The early adopter programme was independently evaluated and alongside feedback from our early adopters has informed the development of the PSIRF (2022).

The evaluation report is available on our FutureNHS workspace.

List of early adopters

Listed by region, we would like to thank the following early adopter organisations that have been instrumental in the development of the final version of the PSIRF:

East

Norfolk and Suffolk NHS Foundation Trust

East Suffolk and North Essex NHS Foundation Trust

Essex Partnership University Foundation Trust

West Suffolk NHS Foundation Trust

NHS Suffolk and North East Essex ICS

London

London Ambulance Service NHS Trust

North West London Collaboration of ICSs

Midlands

Chesterfield Royal Hospital NHS Foundation Trust

Derbyshire Community Health Services NHS Foundation Trust

Derbyshire Healthcare NHS Foundation Trust

Derbyshire Health United

University Hospital Derby and Burton NHS Foundation Trust

NHS Derby and Derbyshire ICS

National

Care UK (Independent provider of healthcare in prisons)

North East and Yorkshire

Leeds Teaching Hospitals NHS Trust

NHS Leeds ICS

North West

East Lancashire Hospitals NHS Trust

NHS East Lancashire

South East

Isle of Wight NHS Trust

NHS Isle of Wight

South West

Cornwall Partnership NHS Foundation Trust

North Bristol NHS Trust

Royal Cornwall Hospitals NHS Trust

NHS Kernow

Get in touch

If you would like to get in touch, please contact Patientsafety.enquiries@nhs.net.

Alternatively, you can use the PSIRF discussion board on our FutureNHS platform.

# data[].attributes.attachment_link.title
NHS England » Patient Safety Incident Response Framework

# data[].attributes.attachment_link.description
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.

# data[].attributes.headline
Term of Reference (ToR) for investigation. 

# data[].attributes.subject
Term of Reference (ToR) for investigation. 

# data[].attributes.headline
PSIRF planning - Pressure ulcer example scenario

# data[].attributes.subject
PSIRF planning - Pressure ulcer example scenario

# data[].attributes.headline
Incident response decision making flowchart

# data[].attributes.subject
Incident response decision making flowchart

# data[].attributes.headline
Learning Response Review and Improvement Tool. 

# data[].attributes.subject
Learning Response Review and Improvement Tool. 

# data[].attributes.attachment_link.title
Learning response report review _ improvement tool_General_03.7.23_V03

# data[].attributes.headline
The investigator's toolkit: Using Appreciative Inquiry in safety investigations

# data[].attributes.subject
The investigator's toolkit: Using Appreciative Inquiry in safety investigations

# data[].attributes.attachment_link.title
Using Appreciative Inquiry in safety investigations

# data[].attributes.attachment_link.description
In the first in a series of blogs looking at the range of investigation methods used by HSIB, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportunities for learning.

# data[].attributes.headline
After Action Review Report. Whittington Health NHS Trust

# data[].attributes.subject
After Action Review Report. Whittington Health NHS Trust

# data[].attributes.headline
HDB/AAR template Isle of Wight NHS Trust (South East)

# data[].attributes.subject
HDB/AAR template Isle of Wight NHS Trust (South East)

# data[].attributes.headline
Using Education to Engage Staff in Supporting Those Involved in Patient Safety Incidents (20th April 2023)

# data[].attributes.subject
Using Education to Engage Staff in Supporting Those Involved in Patient Safety Incidents (20th April 2023)

# data[].attributes.headline
Accounts of real After Action Reviews (iTS Leadership 2023)

# data[].attributes.subject
Accounts of real After Action Reviews (iTS Leadership 2023)

# data[].attributes.attachment_link.title
Accounts of real AARs iTS Leadership 2023

# data[].attributes.headline
After Action Review (AAR) Essex Partnership University NHS FT

# data[].attributes.subject
After Action Review (AAR) Essex Partnership University NHS FT

# data[].attributes.attachment_link.title
After Action Review template - updated 14.09.21

# data[].attributes.headline
Harm Grading Guidance (University Hospitals of Morecombe Bay NHS Foundation Trust

# data[].attributes.subject
Harm Grading Guidance (University Hospitals of Morecombe Bay NHS Foundation Trust

# data[].attributes.headline
Copy of Incidents Response Standards Gap Analysis

# data[].attributes.subject
Copy of Incidents Response Standards Gap Analysis

# data[].attributes.attachment_link.title
Copy of Incident Response Standards Gap Analysis

# data[].attributes.headline
Standard Operating Procedure (SOP)PSIRF ICB sign off process for smaller independent providers (Suffolk and North East Essex)

# data[].attributes.subject
Standard Operating Procedure (SOP)PSIRF ICB sign off process for smaller independent providers (Suffolk and North East Essex)

# data[].attributes.attachment_link.title
20230215-02 SOP - Smaller independent providers 0.5

# data[].attributes.headline
Pressure Ulcer After Action Review (AAR) template shared by West Suffolk NHS Foundation Trust

# data[].attributes.subject
Pressure Ulcer After Action Review (AAR) template shared by West Suffolk NHS Foundation Trust

# data[].attributes.attachment_link.title
Pressure Ulcer AAR Template v4 Sept 2022

# data[].attributes.headline
iTS After Action Review (AAR) template and questions

# data[].attributes.subject
iTS After Action Review (AAR) template and questions

# data[].attributes.headline
Understanding the new NHS Learning Response Tools

# data[].attributes.subject
Understanding the new NHS Learning Response Tools

# data[].attributes.attachment_link.readable_text
Learning Response Tools (LRTs) are exactly what they say they are: tools that are designed to facilitate learning in response to an event, most often an adverse one. With the recent publication by NHS England of the new Patient Safety Incident Response Framework (PSIRF), a wider range of learning response tools is being recommended to enable a more proportionate and compassionate response to low, moderate, or serious harm events.

To help patient safety leads, governance teams and risk managers who are responsible for their organisations' patient safety incident response policies, we have written a comprehensive guide to the similarities and differences between each of the LRTs and summarised the key features of each in table form. There is a surprising amount of confusion about what each of the LRTs entails, so we want to promote their correct application, and support healthcare providers select the right tools for this important work.
Slides - The Four PSIRF Learning Response Tools Summarised Article - The PSIRF Learning Response Tools explained
There are obvious similarities between the different recommended LRTs - such as the intention to create a safe, no-blame environment and a series of questions to guide the process - but it is the differences between them that bring real clarity about the benefits of each and when it is best to use them.

Organisations are being asked to "balance effort between learning through responding to incidents or exploring issues and improvement work." Our guide will help you understand how to achieve this.

# data[].attributes.attachment_link.title
Understanding the new NHS Learning Response Tools - iTS-AAR

# data[].attributes.attachment_link.description
Learning Response Tools (LRTs) are exactly what they say they are: tools that are designed to facilitate learning in response to an event, most often an adverse one. With the recent publication by NHS England of the new Patient Safety Incident Response Framework (PSIRF), a wider range of learning response tools is being recommended to enable a more proportionate and compassionate response to low, moderate, or serious harm events.

# data[].attributes.attachment_link.readable_text
Patient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimize learning and take action to prevent further incidents occurring. Good practice in incidents investigation has been described by the NPSA in the London Protocol. A key step in this protocol is the identification of all contributory factors. The Clinical Human Factors Group also recommends effective contributory factor analysis as part of serious incident investigation.
In 2012, a systematic review of 83 research studies focusing on the causes of hospital patient safety incidents was conducted. The result of this piece of work is the first evidence-based framework of accident causation in hospitals: the Yorkshire Contributory Factors Framework.

The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimizing learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Please refer to the BMJ document in the "Further Information" section above.

Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The YCFF includes all sixteen domains of the evidence-based domains. Through an iterative process with input from risk managers, clinicians and human factors experts, the document has been improved. Feel free to download and adapt the latest version by clicking on the image below:

The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents. These factors can then be addressed through changes in systems, structures and local working conditions. Finding the true causes of patient safety incidents offers an opportunity to address systemic flaws effectively, for the benefit of all our future patients.

# data[].attributes.attachment_link.title
Yorkshire Contributory Factors Framework - Improvement Academy

# data[].attributes.attachment_link.description
Patient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimize learning and take action to prevent further incidents occurring. Good practice in incidents investigation has been described by the NPSA in the London Protocol.

# data[].attributes.attachment_link.title
PSIRF planning_pressure ulcer example_ v 1.2 (1)

# data[].attributes.headline
HSIB. Safety investigation Jargon buster. (linked from Tavistock and Portman NHS Foundation Trust on Patient Safety Learning's hub)

# data[].attributes.subject
HSIB. Safety investigation Jargon buster. (linked from Tavistock and Portman NHS Foundation Trust on Patient Safety Learning's hub)

# data[].attributes.headline
PSIRF Resource guide. A reference guide for PSIRF resources. July 2023

# data[].attributes.subject
PSIRF Resource guide. A reference guide for PSIRF resources. July 2023

# data[].attributes.headline
Transitioning to PSIRF: separating fact from friction 

# data[].attributes.subject
Transitioning to PSIRF: separating fact from friction 

# data[].attributes.attachment_link.title
PSIRF_separating fact from fiction_v 1.0 (1)

# data[].attributes.headline
This initiative is supported by the Supporting Q Connections Programme. Q is led by the Health Foundation and supported by partners across the UK and Ireland. 

# data[].attributes.subject
This initiative is supported by the Supporting Q Connections Programme. Q is led by the Health Foundation and supported by partners across the UK and Ireland. 

# data[].attributes.headline
Bradford PSIRF staff leaflet . June 2023

# data[].attributes.subject
Bradford PSIRF staff leaflet . June 2023

# data[].attributes.headline
BMJ article - Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report

# data[].attributes.subject
BMJ article - Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report

# data[].attributes.headline
Patient Safety Incident Response Framework & CEMBooks. A System Engineering Initiative for Patient Safety.

# data[].attributes.subject
Patient Safety Incident Response Framework & CEMBooks. A System Engineering Initiative for Patient Safety.

# data[].attributes.headline
HSIB - Thematic analysis of first investigations. 

# data[].attributes.subject
HSIB - Thematic analysis of first investigations. 

# data[].attributes.headline
Patient Safety Investigator. Quality and Safety. Job Description and Person Specification. (Barking, Havering and Redbridge University Hospitals NHS Trust)

# data[].attributes.subject
Patient Safety Investigator. Quality and Safety. Job Description and Person Specification. (Barking, Havering and Redbridge University Hospitals NHS Trust)

# data[].attributes.attachment_link.title
162-3867-AV-A_Job Description  Person Specification (1)

# data[].attributes.headline
Learn from patient safety events (LFPSE) service Cooms toolkit

# data[].attributes.subject
Learn from patient safety events (LFPSE) service Cooms toolkit

# data[].attributes.attachment_link.title
LFPSE - comms toolkit v1.0 - Universal deck - Jan2023

# data[].attributes.attachment_link.readable_text
The project has created investigation resources to support you if you are involved in a Patient Safety Incident Investigation either as a patient, family member, healthcare staff member or investigator. By navigating to one of the pages below, you can download the relevant co-designed guidance or support booklets which contain helpful information to guide and support your involvement in an investigation.

# data[].attributes.attachment_link.description
Investigation resources The project has created investigation resources to support you if you are involved in a Patient Safety Incident Investigation either as a patient, family member, healthcare staff member or investigator.

# data[].attributes.headline
PSIRF template leaflet/summary for Comms  teams (Practice Plus Group, Secondary Care)

# data[].attributes.subject
PSIRF template leaflet/summary for Comms  teams (Practice Plus Group, Secondary Care)

# data[].attributes.headline
Job Description and Person Specification. Patient Safety Investigator. Quality and Safety

# data[].attributes.subject
Job Description and Person Specification. Patient Safety Investigator. Quality and Safety

# data[].attributes.attachment_link.title
162-3867-AV-A_Job Description  Person Specification (1)

# data[].attributes.attachment_link.description
We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

# data[].attributes.attachment_link.readable_text
Accessibility

Whether the design of the interface, layout, and storage facilities consider the range of end user capabilities e.g. physical, neurodiversity, in design for the reliability, ease and efficiency of use AND the time and place where it is needed.

Adjustments

Modifications of a task, which are considered necessary in a given context to achieve work goals e.g. safety, efficiency, wellbeing in the time, environment and presenting circumstances.

Affordances

Where the appropriate use or operation of an item is conveyed in its design e.g. a handle on a door that implies it should be pulled not pushed.

ALARP / SFAIRP

'As low as reasonably practicable'/'so far as is reasonably practicable' (terms used interchangeably). The level to which we expect to see workplace risks controlled by weighing a risk against the trouble, time and money needed to control it (see more on the Health and Safety Executive website).

Anthropometry

A measurement of physical characteristics among a population (e.g. elbow to fingertip length) recorded in either a fixed position, or whilst in motion. There are many such dimensions and, in knowing their range, these inform the physical design of objects and workspaces.

Attention

The focus of our cognitive process in the direction of a specific item or activity to consider information or our environment.

Automaticity

The ability to intuitively know what to do and to quickly recognise critical aspects of a situation (Juliusson et al, 2005), which requires less mental effort.

C

Capabilities

Features of individuals that influence what they can achieve. They encompass physical, psychological and social characteristics, which may be influenced by conditions that enhance or limit performance.

Closed question

A question asked in such a way as to expect response in a limited way - such as the provision of specific detail, or a response that is either positive or negative.

Cognitive bias

Cognitive bias can only be judged in hindsight and may not be a helpful term for healthcare investigations. Consideration to why performance may have made sense at the time and organisational influences would reflect a systems approach to considering any identified bias.

Cognitive interviewing

The use of techniques that aim to improve the reliability of interviewee recall, the quality of the information provided and to fully explore the decisions and actions taken in the context of the event.

Cognitive tasks

Activities that require mental activity from a person, such as concentration, vigilance, memory recall, detection of signs or of feedback, processing information, decision-making, judgements and problem solving.

Commission (slip)

See 'slip'.

Communication

The sharing of information, a response, thoughts, and feelings through any medium e.g. spoken, written, electronic.

Competence

Recognised level of performance, and use of knowledge and skills to do something successfully and efficiently.

Complex system

A complex system refers to systems that evolve rather than being designed by an organisation. A complex system will have many interacting parts that exists in a context of uncertainty and may lead to emergent outcomes that may not be predictable.

Complexity of task

A task that may require specialised knowledge, skills and experience to undertake a particular activity or a task that has multiple parts, which require precision and a high level of attention.

Configural maps

A visualisation of the interaction of the system elements relevant to a specific healthcare process. This can assist in presenting and understanding the emergent properties of the interactions.

Constraints

Factors that influence or define a design to assist in correct use or application e.g. regulations and standards, physical controls, context or resources available.

Contextual factors

The factors within the environment or organisation relevant to the background of the work and events reported by staff.

Contributory factors

Factors influential to an event or outcomes. They may be separated in space and time from the actual event itself, and even from outside the organisation involved.

Coping

How individuals may vary in managing their reaction e.g. stress to a situation. There are different styles of coping:

problem (task) focused coping

emotion focused coping (avoidance or selective attention)

avoidance coping (actively avoid / distraction).

Counterfactual reasoning

Counterfactual thinking is a concept that involves the human tendency to create possible alternatives to life events that have already occurred; something that is contrary to what actually happened. Counterfactual thinking is, as it states: "counter to the facts" and incident reports that fall into this trap include words like 'they could or should have done...'.

Culture

A reflection of the way that things are done or managed in any particular workspace or across an organisation.

Currency (of skills/training)

Having up to date skills, experience and knowledge of practices in the workplace.

D

Decision-making

The interpretation of information sources available to choose an action plan within the time required.

Design

Activities that have the goal of developing a product, environment or process that is compatible, safe and desirable for those intended to use, work or experience the design.

Design (of a task)

What a person has to do. That it is undertaken in a logical way; that it aligns with a person's capabilities (and limitations); and that it fits well with the demands of other activities associated with a person's role (e.g. to provide safe and efficient care).

Distal outcome

An outcome that is not immediately obvious and identifiable close to the event, but takes effect in the longer term and/or in circumstances that are not directly features of the actual incident event or conditions.

Distributed cognition

Where information is not only within a person's mind but incorporates input from the technology and environment (the system) in which thought processes occur and enables multiple people to share knowledge and a common mental model of a situation.

Donabedian model

A foundation approach to evaluation of quality of care. There are three areas of focus - the structure (factors such as facilities, technology and people), the processes (adopted to deliver patient care), and outcomes (as reflected in patient health and quality of life).

Duty of Candour

A regulatory requirement for care providers to be open and transparent with service users and includes situations where things have gone wrong with care or treatment. The requirements span communication, support, truthfulness and an apology (see Guidance: Duty of Candour, 2020 on the GOV.UK website).

E

Emergent/emergence

Outcomes that result from the interactions between elements in the system that cannot be fully explained or always predicted by examining the elements separately (Hollnagel et al. 2006). Emergent outcomes may sometimes seem disproportionate to the interactions, or the characteristic of the elements involved.

Entities

The components of the system, such as the people, the equipment, documentation etc., but also less tangible things such organisational culture and external social, political or legal influences.

Ethnography

A method where researchers observe and/or interact with a study's participants to record the context and real-life environment.

External factors

The external environment influences patient safety and quality of care by shaping the context in which care is provided. In modern healthcare systems these external forces are stronger and change more frequently than ever before.

F

Family engagement

The prompt, effective liaison between a family and an investigation team to ensure the family is integral to the investigation and is treated professionally, respectfully and according to their individual needs.

Fatigue

A physiological state of reduced mental or physical performance resulting from sleep loss, extended wakefulness, time of day and/or workload (mental and/or physical activity) that can impair a person's alertness and ability to perform safety related operational duties' (modified from International Civil Aviation Organization, 2015, page xiii).

Feedback

The extent to which a user is aware of their interaction (both successful and unsuccessful) with technology.

FRAM

Functional Resonance Analysis Method. Supports the analysis and creation of a model depicting how work processes interact and where variability may exist in the context of everyday work.

G

Gap analysis

The steps taken to support the development of knowledge and understanding of an area of enquiry by identifying evidential gaps to be addressed, to ensure a comprehensive set of evidence informs the analysis and conclusions made within an investigation.

H

Healthcare human factors/ergonomics

A scientific discipline that seeks to understand the interactions between humans and the elements of systems in which they provide or receive care/service. This knowledge is used to optimise system design for human well-being and overall performance.

Healthcare Safety Investigation Branch (HSIB)

HSIB completes investigations that look at factors that have harmed or may harm NHS patients. HSIB works closely with patients, families and healthcare staff affected by patient safety incidents, and never attributes blame or liability.

HSIB investigations are delivered through two programmes: national and maternity. There are differences in how they are carried out and how reports are published but the aims are the same: to share learning and to make safety recommendations that improve safety at a national level.

Heuristic

Mental shortcuts we use in everyday decision making, in situations that are familiar to experienced people.

Hierarchical task analysis (HTA)

A technique that isolates the steps, actions and pre-conditions needed for the successful completion of a task. It is commonly presented as a diagram which depicts the sequence of actions as a hierarchy.

Hierarchy of control

A strategy for risk control that promotes an intervention approach through sequentially considering those that are potentially more effective and protective. The hierarchy moves from those considered to have most impact (such as removal or substitution of a hazard) through to controls that isolate people from hazards, or introduce administrative controls that change work practices (see: The National Institute for Occupational Safety and Health, 2020 on the Centers for Disease Control and Prevention website).

Hierarchy of intervention effectiveness

A strategy for risk control that compares both efficacy and difficulties of intervention choices. Those most effective, albeit harder to implement, typically concern design changes. Those with medium efficacy have greater demands for 'updating or reinforcement', whereas those with lesser efficacy, albeit easier to implement, are reliant on behaviour change.

Human error

A hindsight judgement that attributes blame to individuals involved in an incident. It is a symptom of underlying systems issues within which error was able to occur.

Human Reliability Analysis (HRA)

A family of approaches (over 75 methods) that looks at the different ways in which people can fail, such as predicting human error likelihood and assess their impact on the task. Also known as 'Human Failure Analysis' it should be based on 'work as done' (albeit can inform 'work as imagined').

I

Incivility

Impolite or unsociable communication or behaviour that contravenes the norms of respectful interaction. It can appear in varied forms, such as bullying, passive aggression or verbal abuse, and may have an impact upon safety.

Inclusion

Active steps taken to avoid discrimination or alienation of any particular stakeholder (e.g. giving equal access irrespective of race, gender, social diversity, disability, medical or other needs).

Inclusive design

Where an item is designed to be accessible and usable by as many intended end-users as possible without the need for further adaptations.

Inclusive report

A means of presenting an investigation report that is accessible to all stakeholders and enables learning in a way that is usable and meaningful to the intended audience.

Information processing

How knowledge is acquired, updated and modified (abridged, Christie and Gardiner, 1990).

Interactions

Where features of one or more entities combine to produce an outcome or impact performance. In an investigation we seek 'clusters' and themes of prominent interactions that can explain and 'tell the story' around how system factors contributed to the outcome or incident.

Interface

The screen, control system or physical features of a product or tool which influences how easily a user can understand and interact with it.

Investigative interviewing

A purposeful and meaningful conversation that aims to maximise the amount and quality of information that will enhance understanding of the how and why something occurred or didn't occur.

J

Just culture

"A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution", Professor Sir Norman Williams Review on the GOV.UK website.

L

Lapse

Failure to do something, such as missing a step in a procedure (an omission).

Leading questions

A question that is asked in such a way as to prompt or encourage the respondent to answer in a specific or particular manner based on the way the question is framed.

A visual representation to enable analysis of a work environment, social network or lines of communication. It charts the lines of travel taken from one system entity to another and informs layout design, interactions within a team or across a workplace. Typically used in observation of a series of activities within a workspace (e.g. walk through talk through (WTTT)) to understand the frequency, sequence, and importance of specific interactions and can identify variability or potential for redesign.

Local rationality

Seeking to understand why practices and processes made sense at the time of an event, through exploring the nature of the work, the personal and team goals and prevailing systems conditions.

Long-term memory

Information in the mind that is stored and that can be retrieved following a few hours, days or years.

M

Mental model

The representations we create in our minds of external events. These are individual but when team working is necessary a shared mental model is how effective teamwork and communication can be supported.

Mental workload

The demands placed on a person's cognitive capabilities (resources) by a task or activities. Successful performance is influenced both by overload and underload

Mistake

A failure of decision-making - doing the wrong thing but believing that it is correct. Can arise when following incorrect rules for a particular event.

Multi-tasking

Paying attention to and undertaking of two or more tasks in a similar timeframe.

N

Never events

Patient safety incidents that can cause harm (or have the potential to do so) and are "wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers", NHS Improvement (2018).

O

Occupancy

The residual free room in a workspace, that is not taken up by furniture, storage, fittings and equipment, for people to move around and freely use a work area.

Omission

See 'lapse'.

Open prompt questions

Posing sentences that include key words, such as 'tell me', 'explain', 'describe' and 'show me', that help elicit perspective and allow for more conversational exchange.

Open question

A question worded in such a way as to enable an interviewee to provide a descriptive answer, using their own choice of words.

Organisational culture

The unconscious norm within an organisation concerning values, practices and assumptions.

Organisational learning

A continuous cycle of action and reflection, which takes place at different levels, including the individual, the team or department, the organisation and the NHS as a whole (see: 'Achieving sustainable change' on the Chartered Institute of Ergonomics & Human Factors website).

Outcome

An emergent property, wanted or unwanted, affecting human or system performance.

Oversight

A 'helicopter view' of what is going on. A term that describes the practice of situational awareness.

P

Patient work

Activities required of patients in the complex system, such as complying with conditions needed to receive treatment and in providing feedback to clinicians.

PEACE model

An investigative interviewing model detailing stages from preparation and practice to closure and evaluation. Used alongside a systems based investigative model (such as SEIPS) in healthcare.

Performance influencing factors

Aspects of the work system that can have both immediate and latent (background) effect on individual or organisational performance (the effectiveness of things) and may also contribute to unwanted outcomes. Also known as performance shaping factors.

Performance variability

Variation in the way that work is completed and the degree to which goals are adjusted, in accordance with individual capabilities, organisational capacity/resources and the needs of everyday work. There may be resulting trade-off in efficiency and thoroughness by individuals or a team (depending on work condition and demands), and outcomes may or may not be as intended.

Personal characteristics

The various individual traits that impact performance and capability, including:

personality

attitudes

aptitude

confidence

morale

physical and/or mental health status

Physical tasks

Both static and dynamic activities of the body that place demands on a person's energy expenditure. The personal experience and task performance are impacted by:

individual capabilities and the nature of opportunities to recover

duration and frequency of exposure

suitability of tools/technology and workspace for those undertaking the task

compatibility with other work requirements.

Procurement

The purchase of products and services to fulfil staff and patient work requirements.

Prototyping

The mock up and testing of early design ideas to enable progressive development of a design while preparing to create a final product. Incorporating user testing, evaluation and iterative development in order to fine tune and optimise performance.

Proxies

The varied investigative techniques (e.g. observation, interview, analysis of existing records data or guidance) that contribute to the understanding of how 'work is done' in an investigation. In isolation each provides only a partial representation (such as in 'work as imagined' or 'work as disclosed'). It is in their collation (or 'triangulation') that a depth of understanding of 'work as done', and the system in which work occurs, can be built.

Proximal outcome

An outcome that is 'of the moment' and occurs and identified within the context of the incident.

Psychological safety

A shared understanding within a team that you can speak up with ideas, questions or concerns, without fear of embarrassment or humiliation.

Psychosocial safety

Providing opportunities for people to control possible sources of stress through managing their workload, work scheduling and ways of working.

R

Recommendation

A statement to indicate the system improvement required. Recommendations from an investigation will result from analysis of themes identified in an investigation and may be achieved using a variety of possible ways.

Reliability (validity)

The likelihood of consistent achievement of an intended performance e.g. a task, use of equipment, delivery of a service or care.

Requirements generation

Preparation of baseline criteria to develop a design. Design requirements consider what is functionally and technically required, the intended end users and known constraints.

Risk perception

The recognition and judgement made on potential hazards and the likelihood that harm (or failure) may occur.

Root cause analysis

A predecessor linear investigation approach that was used to isolate deep underlying causes of an event in simpler or engineered systems.

S

Safety case

A compilation of claims and evidence that gives assurance that a system, within a specified context, can be operated safely.

Safety climate

The local workforce attitudes and perceptions at a given point in time.

Safety culture

Combination of values, perceptions, beliefs, and leadership styles which lie below the surface and define the landscape. They are not easily visible without 'diving' below the surface.

Safety I

Safety-I approach presumes that things go wrong because of identified failures or malfunctions of specific components: technology, procedures, the human workers and the organisations in which they are embedded. Investigation in Safety-I is to identify the causes and contributory factors of adverse outcomes and failures. The safety management principle is to respond when something happens or is categorised as an unacceptable risk, usually by trying to eliminate causes or improve barriers, or both (see: From Safety-I to Safety-II: A White Paper by Professor Erik Hollnagel on the NHS England website).

Safety II

Safety-II approach assumes that everyday performance variability provides the adaptations that are needed to respond to varying conditions, and hence is the reason why things go right. Humans are consequently seen as a resource necessary for system flexibility and resilience. In Safety-II investigations seek to understand how things usually go right, since that is the basis for explaining how things occasionally go wrong. Risk assessment tries to understand the conditions where performance variability can become difficult or impossible to monitor and control (see: From Safety-I to Safety-II: A White Paper by Professor Erik Hollnagel on the NHS England website).

Safety science

A multidisciplinary research driven approach to understanding how hazards and their risk of harm to people and their wellbeing can be reduced or prevented.

SEIPS

'Systems Engineering Initiative for Patient Safety' is a framework that can be used in understanding inter-relationships across the structures, processes and outcomes in healthcare (see resources in Canvas, the online learning management system for those enrolled on an HSIB course).

Sensory input

Information received by any of the senses, such as:

SHERPA

Systematic Human-Error Reduction and Prediction Approach (Embrey, 1986). A technique that builds upon a hierarchical task analysis (HTA) to support understanding of performance influencing factors and identification of potential errors that may occur at each stage of a task. It also promotes consideration of error reduction recommendations that might be directed at procedures, training and equipment design.

Signifiers

Through use of a sign or other form of indicator identifying how an action should be performed.

Situational awareness

A concept that refers to the ability to have real time knowledge and anticipation of what is and is about to happen. Consideration to how well information, equipment and processes can support an awareness of a situation needs to be considered in a systems-based investigation.

Situational factors

The range of factual details (e.g. quality and reliability of available information, communications, acuity, workforce) specific to the time and place in which the event occurred.

Skill based error

An error made when undertaking a familiar activity that doesn't require much attention.

Skills, rule knowledge classification

A form of classifying human performance and behaviour (derived by Rasmussen, 1983) according to demands, or requirements, expected of an individual. 'Skill' behaviour is familiar and can be undertaken with little concentration. 'Rule' behaviour is more complex but requires the pursuit of familiar instructions. 'Knowledge' behaviour is a novel scenario that requires planning and decision making.

Slip (commission)

A form of skill-based error where there has been failure in carrying out part of an activity (such as missing out a step, an incorrect sequence, or incorrect use of equipment).

Sociotechnical system (STS)

Recognition both of the social needs of people (staff, patients and those supporting them) and of their work and organisational situation (e.g. technology and the work environment). Optimising design/fit across both entities promotes mutually beneficial performance, wellbeing and safety outcomes.

Stakeholders

Individuals or key groups representing patients, staff and those providing services to enable care. Able to support the development of the terms of references for an investigation, provide pertinent evidence and contribute to the application of learning in decision-making.

Standardisation

Deliberate uniformity across the features of tools and technology (i.e. in their presentation and operation) to be easily identified to assist reliable and ease of use.

Storytelling

The sharing of details that describe a sequence of events in an investigation in a meaningful way. Combined, the reader might develop insight and an ability to visualise both the unfolding of a scenario and how contributory factors influenced the outcome.

Stress

Stress is a consequence of the relationship between the person and their environment, an interaction, rather than a property of an individual. How much an individual believes they are in control influences the stress they will experience and hence how they will cope.

System

A 'system' describes a set of activities or parts that interact and have a shared purpose; where the effectiveness of the whole system is greater than the sum of the parts (abridged: Wilson, 2014).

Systemic barriers

The strongest type of safety control is referred to as a barrier. The term barrier has a distinct description within safety industries as "A risk control that seeks to prevent unintended events from occurring, or prevent escalation of events into incidents with harmful consequences" (International Association of Oil and Gas Producers, 2016).

Systems approach/thinking

A mindset of ensuring that an investigation explores the multiple interacting contributory factors across the care system. That these are explored in seeking to understand the differing entities and activities that may (over time) contribute to an outcome or an incident.

Systems frameworks

A diagram or model that serves as a guide, and that depicts core areas of enquiry for an investigation to explore significant interrelationships of system factors represented within the framework.

T

Task

A specific action undertaken under specific conditions, with a particular goal, which takes place within wider work processes or activities.

Team work

The working co-operatively together among a group of people towards a common goal, through distributed roles, authorities, responsibilities, skills and capabilities.

Terms of reference

The scope of an investigation that defines the boundary of the system and healthcare processes to be considered within an investigation, combined with a rationale for what isn't considered. The development of terms of references requires the different perspectives of stakeholders and should include representatives that include patients, family/carers and staff.

Thematic analysis

The process of examining and assigning codes to text (e.g. incident narratives), in order to identify and group information into common themes. This assists in the interpretation across a range of inter-related data and can support learning across multiple investigations.

THERP

Technique for Human Error Prediction Rate (Swain and Guttmann, 1983). A comprehensive methodology used to assess human reliability. It incorporates the way that task errors are identified, visually represented and quantified.

Timeline

A chronology of events, incorporating details from a range of possible resources, that provides a temporal sequence of what happened as reported or recorded within the period of time around an incident.

Training

Facilitating the development of a behaviour or skills, encompassing aspects influencing access to training; quality of content, style and delivery for user needs; and skill consolidation and retention.

Training issues

Aspects that affect access to training (such as recognition of training needs and resourcing), provision of training (appropriacy of delivery style, duration and content; trainer skills) and measures for skills consolidation and maintenance.

U

Universal design

Design intended to accommodate as many people as possible: a 'one size fits all' concept.

Up and out v.s down and in

Balancing the investigation focus across the details of an incident. Increasing the effort to not just understand the 'who', 'what' and 'when' details to also understanding the 'how' and 'why' which can inform on the influence of the decision making and wider system factors (e.g. regulations, policy, targets, training, procurement), that influence practice and processes on a day-to-day basis.

Usability

An outcome that determines how successfully a product or process supports the interaction between a person and a product, in its context of use, to create an effective, efficient, and satisfying outcome.

User-centred design

An approach to the design of activities or equipment which engages the user early on to ensure the intended use and environment is considered to enhance ease of use and reduce errors.

W

Walk through talk through (WTTT)

A data collection method that supports observation, discussion and understanding of particular practices, tasks, or scenarios as they are 'in practice'. Undertaken on location, it incorporates as much of the typical working conditions (environment, staff, equipment) as is safe and feasible, and supports development of Work as Done (WAD) knowledge.

Work As Done/Work As Imagined

Understanding how day to day work is actually undertaken (Work as Done) compared with a belief of how work is undertaken (Work as Imagined), for example in procedures and guidelines. The comparison can reveal gaps between insights of frontline staff and those more removed from everyday work practices e.g. managers, governance leads.

Working memory

Information that is stored for a brief period and accessible for retrieval where its use supports comprehension for achievement of a particular goal.

Working scheduling

Features concerning the management of working time, with particular reference to the nature of work demands, including aspects such as shift systems, the pacing of work, and work-rest patterns (e.g. duration or work relative to opportunity for rest and recovery, and work pacing).

Workload

Workload describes the demands experienced by an individual from physical and cognitive activities (work) and the perceived effort required to complete them. Performance can be affected both by activity overload and underload.

# data[].attributes.attachment_link.description
Whether the design of the interface, layout, and storage facilities consider the range of end user capabilities e.g. physical, neurodiversity, in design for the reliability, ease and efficiency of use AND the time and place where it is needed. Modifications of a task, which are considered necessary in a given context to achieve work goals e.g.

# data[].attributes.headline
Applying the Patient Safety Incident Response Framework (PSIRF) within maternity and neonatal services. 

# data[].attributes.subject
Applying the Patient Safety Incident Response Framework (PSIRF) within maternity and neonatal services. 

# data[].attributes.attachment_link.title
Applying PSIRF in maternity  neonatal  - SLIDES 12.07.2023_

# data[].attributes.headline
Y&H PSIRF Learning Community: PSIRF for Maternity Teams. 28th April 2023

# data[].attributes.subject
Y&H PSIRF Learning Community: PSIRF for Maternity Teams. 28th April 2023

# data[].attributes.attachment_link.title
PSIRF & maternity LC meeting April 23 V1

# data[].attributes.headline
The Leeds Teaching Hospitals NHS Trust 03/02/2022

# data[].attributes.subject
The Leeds Teaching Hospitals NHS Trust 03/02/2022

# data[].attributes.attachment_link.title
NORTH EAST AND YORKSHIRE Leeds Teaching Hospital NHS Trust_FINAL