Understanding PSIRF
The Patient Safety Incident Response Framework (PSIRF), NHS England is an NHS approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.
Only NHS provider organisations must apply the framework under the NHS standard contract. However, PSIRF principles and tools could be translated and used locally to deliver improvements in any organisation. Integrated Care Boards (ICBs) can offer oversight to drive and support delivery of improvements within organisational Patient Safety Incident Response (PSIR) plans.
PSIR plans
An organisational PSIR plan sets out how an organisation intends to respond to patient safety incidents over a set period, usually 12 to 18 months.
It can be used to detail the organisational patient safety priorities. It acts as a clear guide for where to invest limited time, energy and resources related to improvement work.
In this 9-minute video, Lauren Mosley Head of Patient Safety Incident Response Policy at NHS England describes how PSIRF and a well designed PSIR plan can support organisational medication safety improvement work.
PSIRF training
Rolling out training to upskill healthcare professionals in PSIRF principles within an organisation can support the cultural change required to deliver improvement against PSIR plans. It supports organisations to embed a systems-wide approach and a proportionate, compassionate response to safety events. In turn, it can support the prioritisation and delivery of medication safety improvement initiatives identified within a PSIR plan.
NHS England
Resources related to PSIRF are available from NHS England. These provide an introduction to PSIRF and related tools, available as podcasts and videos as well as written resources.
Recordings of previous webinars are also available on the NHS Patient Safety Futures workspace (log in required). The PSIRF in practice webinar series focusses on sharing the experience and insight from those working on and informing the work being done across our systems to embed PSIRF. The Patient Safety Incident Response Plan template review webinar gives advice on reviewing your local plans.
Health Services Safety Investigations Body (HSSIB)
A HSSIB report shares learning and insights from their experience of patient safety incident investigation under PSIRF. Aimed at national and local organisations and policymakers, the report aims to help inform future work to support staff in system-based investigation. The Building Investigation Excellence strategy, HSSIB supports investigators of incidents to deliver improvement in patient safety.
Benefit of including medication safety in PSIR plans
Organisational medication safety improvement delivery can be strengthened through the high-level oversight that inclusion in an organisational PSIR plan provides.
Embedding medication safety within an organisational PSIR plan can help to support prioritisation of resources and active engagement. It can align long-term medication safety goals with organisational safety priorities, shifting the focus of medication safety initiatives into intentional and impactful organisation-wide improvement projects.
Identifying priorities
Triangulation of a range of insights provides a shared understanding of medication safety risks within an organisation. It also highlights where medication safety improvement initiatives can fit in to the organisation’s delivery against the NHS Patient Safety Strategy, NHS England.
Insights can come from a range of sources, including incident data, thematic analysis from learning responses, external sources and stakeholders.
Incident data and thematic analysis from learning responses
Outcomes from PSIRF learning response tools and organisational safety data can support local decision making. Thematic reviews can create a safety profile that identifies key system vulnerabilities and priorities. See our article Learning from medication safety events (SPS page) for further information.
External sources
External sources can be a useful source to identify issues for consideration, however improvement initiatives prioritised within an organisation should reflect what matters most to local patient care. External sources include:
- National medication safety priorities, such as those included in the national Medication Safety Improvement Programme (MedSIP) and Primary Care Patient Safety Strategy
- Patient Safety Commissioner priorities
- National Patient Safety alerts
- HSSIB investigation reports
- ICB priorities
- Healthcare Inequalities Framework
Stakeholder engagement
A deep dive into organisational processes and systems may uncover local systemic issues that need to be addressed as a priority. Conversations with frontline staff about ‘what keeps them awake at night’ may provide intelligence that can’t be found through data and reporting. A good priority is rooted in what matters most to those on the frontline either providing or receiving the care, rather than external pressures.
Delivering improvement
Organisations may range from having minimal medication safety improvement initiatives on their organisational safety improvement plan, to having more than 5. The number of improvement initiatives will vary dependent on organisational resources and priorities and will need to balance the desire to deliver results across multiple issues with a commitment to doing less, but doing it well.
Medication Safety Officer leadership
Delivering against an improvement initiative requires effective leadership. Utilising Medication Safety Officers (MSOs) gives both medication safety expertise and professional leadership to an improvement project team.
By embedding the new PSIRF learning response tools and embracing PSIRF principles, MSOs have delivered a more compassionate and proportional response to safety events. An MSO should be in a position to provide the expertise and knowledge required to support effective prioritisation. They are also able to ensure effective collaboration and identification of key stakeholders through medication process and system mapping.
In this 13-minute video, Emma Kirk the National MSO network lead explores the MSO involvement in embedding PSIRF principles within an organisation.
Ensuring effectiveness
Delivering medication safety improvements effectively through the PSIR plan may be supported by:
- Ensuring full understanding of current issues to identify opportunities for future development and improvement.
- Ensuring the improvement initiative detailed within the plan is specific enough to enable focus and demonstratable improvement through measurable outcomes.
- Building strong relationships, communication channels and enabling honesty to deliver improvements. Key stakeholders include MSOs, Patient Safety Specialists and Patient Safety Partners, see Collaboration opportunities to improve medication safety (SPS page) for further guidance.
- Regular reviews to ensure the plan is dynamic and responsive to local need. A successful improvement plan takes time and iteration.
- Ensuring the improvement initiative is focused on a priority risk that resonates with patients and clinicians. Including the rationale for prioritisation of the initiative within the PSIRF plan can promote organisational and senior leadership engagement.
- Wide publication of the plan to staff, patients, families and other stakeholders to improve awareness and encourage involvement, including providing feedback or suggestions.
In this 12-minute video, Liam Wilson Assistant Director Quality Improvement and Patient Care, NHS Hertfordshire and West Essex ICB, shares his experience from being involved in PSIRF delivery across multiple sectors and explores features that support an effective PSIR plan.
Patient involvement
Patients are central to improvement initiatives as it is the patient and carer experience that often drives improvement.
The patient and carer perspective can help prioritise what goes into the organisational PSIR plan. Having a clear plan helps those involved in medication safety events to understand what levels of investigation are required.
A patient or carer input can provide a challenge to those involved in delivering medication safety improvements as being a step removed from a process allows a different perspective. This perspective can also support improvement evaluation, assessing the true impact of a safety improvement initiative.
In this 7-minute video Mark Smith, Patient Safety Partner, shares a patient perspective on the importance of having patient and carer involvement in PSIR plan design and implementation.
In this 17-minute video Mark Smith, Patient Safety Partner, provides his top tips for how healthcare professionals can effectively engage with patient and carers to ensure medication safety is effectively embedded within organisational PSIR plans, plan design and implementation.
Shared good practice
Sharing experiences with improvement interventions and embedding medication safety into organisational PSIR plans can help support effective working practices and open up opportunities for peer to peer support. Examples of organisational PSIR plans with medication safety improvements, and a discussion board to network with peers, can be found on the NHS Futures workspace(opens in a new tab) (login required).
In this 21-minute video Andrew Wilmer, Associate Director Patient Safety and Bianca Levkovich Consultant Pharmacist Medication Safety, both Patient Safety Specialists, share their experience of delivering medication safety initiatives through their PSIR plan at Kings College hospital.
Full webinar recording
The Developing Medication Safety Across The System (MSATS) (SPS page) series of webinars are interactive sessions aimed at HCPs working in any sector with a role within or passion for medication safety.
The recording of the full MSATS: Effectively embedding medication safety into PSIRF is available in the 1 hour 27 minutes video below. Information presented during the webinar and associated videos was correct at time of recording. Current guidance should be followed.