A new approach to patient safety incident response

Dr Tracey Herlihey profile picture

16 August 2022

Dr Tracey Herlihey
Head of Patient Safety Incident Response Policy, National Patient Safety Team
NHS England

Aidan Fowler profile picture

Aidan Fowler
National Director of Patient Safety and Deputy Chief Medical Officer
NHS England/Department of Health and Social Care

NHS England has today published the new Patient Safety Incident Response Framework (PSIRF).

This presents a major step in establishing a safety management system that embeds the key principles of a patient safety culture to focus on understanding how incidents happen, rather than apportioning blame; allowing for more effective learning and improvement, and ultimately safer care for patients.

One of the most exciting things about PSIRF is the freedom and discretion organisations are given to learn and improve the best way they see fit. It removes the 'serious incident' threshold for investigation, instead requiring organisations to create a patient safety incident response plan that is jointly developed and agreed upon by a wide stakeholder group, including patient partners, front line staff, integrated care board members and Care Quality Commission inspectors.

These plans are based on each organisation's local incident profile and existing improvement work, so key areas can be identified for learning response resource to be focussed on, ensuring the resulting learning will have the most benefit on patient safety improvement. This freedom (and the responsibility and accountability it comes with) is what will make patient safety response more meaningful under PSIRF.

A 12-month process of preparation

Our work with early adopters over the last two years and the independent evaluation of the early adopter programme has demonstrated that PSIRF is the right thing to do and a better way forward. This is in terms of both maximising learning and improvement where it will have the greatest impact; as well as providing compassionate engagement with all those affected by an incident, including patients, families, and staff.

Our early adopters described the benefits of PSIRF as:  

  • offering 'better experience for patients and families involved in investigations'
  • 'permission to make decisions on how to respond to incidents in a way that maximises opportunities to learn and improve'
  • 'putting patient safety at the centre of what we do'.

To enable successful implementation, NHS leaders will play an instrumental role in ensuring their organisation is ready to switch from the current Serious Incident Framework to PSIRF, and the new ways of working it introduces.

The switch to PSIRF isn't something that can happen overnight. To support the transition to PSIRF we have published a preparation guide, setting out a 12-month process for organisations to follow through five phases. The purpose of the different phases is described in table 1. We will also offer further support throughout, predominantly via the Patient Safety Collaborative in your Academic Health Science Network area.

Preparation begins with an orientation phase in which organisations become familiar with the documentation and requirements, develop their stakeholder maps, begin important early stakeholder engagement, and form their implementation team. Organisations will move through a 'diagnostic' phase to identify strengths and weaknesses, and ultimately define the necessary improvement in areas that will support PSIRF requirements and the transition.

Importantly, this includes transforming how those affected by patient safety incidents and investigations – including patients, families, carers and staff – are engaged, involved and supported in any opportunity to learn and improve.

Once organisations transition to PSIRF, quality assurance will sit with provider boards and not integrated care boards (ICBs), as has been the norm previously. There will likely be a great deal of uncertainty passing this on to organisations; however, experience from our early adopter programme has demonstrated that ownership and engagement get larger, as well as that more members of the organisation are invested in improvement.

Table 1. Purpose of PSIRF preparation phases


Duration Purpose
PSIRF orientation Months 1–3

To help PSIRF leads at all levels of the system familiarise themselves with the revised framework and associated requirements.

This phase establishes important foundations for PSIRF preparation and subsequent implementation.

Diagnostic and discovery Months 4–7

To understand how developed systems and processes already are to respond to patient safety incidents for the purpose of learning and improvement.

In this phase strengths and weaknesses are identified, and necessary improvements in areas that will support PSIRF requirements and transition are defined.

Governance and quality monitoring Months 6–9 Organisations at all levels of the system (provider, ICB, region) begin to define the oversight structures and ways of working once they transition to PSIRF. 
Patient safety incident response planning Months 7–10

For organisations to understand their patient safety incident profile, improvement profile and available resources.

This information is used to develop a patient safety incident response plan that forms part of a patient safety incident response policy.

Curation and agreement of the policy and plan Months 9–12 To draft and agree a patient safety incident response policy and plan based on the findings from work undertaken in the preparation phases.
Transition Months 12+ Continue to adapt and learn as the designed systems and processes are put in place.

Leaders have a unique opportunity under PSIRF

It will take commitment, time, resources, and perseverance to implement PSIRF effectively, and leaders will play an integral role in supporting their organisations accordingly.

PSIRF enables senior leaders to empower and engage their organisation in learning and improvement rather than more traditional command and control.

Boards have a unique opportunity to do more than measure and monitor and should use their position to influence improvement through curiosity. That is, boards should ask open questions to understand and generate discussion rather than to judge.

More information, including oversight mindset and principles as well as responsibilities in relation to PSIRF oversight is provided in our Oversight roles and responsibilities specification.

A framework for learning and improvement

PSIRF has been in development for a long time. We are grateful for all the support, feedback and effort that has contributed to the development of the framework, from those that responded and shared their views during our initial engagement work in 2018, to the work and determination of the early adopters over the last two years, particularly while working under the pressures of the pandemic.

Our hope is that as NHS trusts progress through the preparation phases, they will share the findings of our early adopter evaluation that this is the right thing to do and a better way forward. Working together, PSIRF can fundamentally change the NHS’s approach to patient safety incident response, supporting learning, improvement and compassion, to make care safer for our patients.

Further information and a range of resources to support organisations to prepare for PSIRF are available on the NHS England website.

About the authors

Dr Tracey Herlihey profile picture

Dr Tracey Herlihey
Head of Patient Safety Incident Response Policy, National Patient Safety Team

At NHS England Dr Tracey Herlihey is responsible for the day to day strategic leadership and subject matter expertise for the Patient Safety Incident Response Framework. Before joining NHS England Dr Herlihey worked at the Healthcare Safety Investigation Branch (HSIB), initially as a national investigator and then as head of safety intelligence.

She is a chartered human factors specialist and chartered psychologist and has a PhD in applied psychology from Cardiff University specialising in human perception and performance. Prior to HSIB, Tracey was a senior human factors specialist at the University Health Network in Toronto, Canada.

Aidan Fowler profile picture

Aidan Fowler
National Director of Patient Safety and Deputy Chief Medical Officer

Aidan Fowler is the national director of patient safety in England and a deputy chief medical officer at Department of Health and Social Care. He was previously the director of NHS Quality Improvement and Patient Safety and director of the 1000 Lives Improvement Service for NHS Wales. He had responsibility for QI/PS across the Welsh NHS and was a board member of Public Health Wales.

Aidan was a consultant colorectal surgeon in Gloucestershire for 10 years and chief of service for surgery for four years before entering the NHS Leadership Academy Fast Track Executive Training Programme during which he worked as an executive at University Hospitals Bristol and subsequently worked briefly as a medical director in mental health and community care in Worcestershire.

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