Patient Safety Incident Response Framework Policy

This document should be read in conjunction with the Patient Safety Incident Response Plan

Purpose

This policy, which has been developed using the national NHSE template, supports the requirements of the Patient Safety Incident Response Framework (PSIRF) and sets out Buckinghamshire Healthcare NHS Trust (the Trust) approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues to learn and improve patient safety.

The PSIRF advocates a coordinated and data-driven response to patient safety incidents. It embeds patient safety incident response into a broader system of improvement, prompting a significant cultural shift toward systematic patient safety management.

This policy supports and promotes the four key aims of PSIRF:

1. Compassionate engagement and involvement of those affected by patient safety incidents
2. Application of a range of system-based approaches to learning from patient safety incidents
3. Considered and proportionate responses to patient safety incidents
4. Supportive oversight focused on strengthening the response system’s functioning and improvement

This policy should be read in conjunction with our current Patient Safety Incident Response Plan (PSIRP), a separate document that outlines the implementation of this policy.

Scope

This policy is specific to patient safety incidents conducted solely for learning and improvement across the services provided by the Trust.

Patient safety Learning responses will follow a “systems-based approach”. A system-based approach recognises that healthcare takes place within a work system composed of people, tasks, equipment, and the various environments in which care is provided.

There is no remit to apportion blame or determine liability, preventability or cause of death in a response conducted for learning and improvement. Responses do not take a ‘person- focused’ approach where the actions or inactions of people, or ‘human error’, are stated as the cause of an incident.

Other processes that exist for that purpose include:

• Claims handling
• Human resources investigations
• Professional standards investigations
• Information governance concerns
• Estates and facilities concern
• Financial investigations and audits
• Safeguarding concerns
• Coronial inquests and criminal investigations
• Complaints (except where a significant patient safety concern is highlighted)

The principal aims of each of these responses differ from those of a patient safety learning response and fall outside the scope of this policy, except where a significant patient safety concern is identified.

Please view or download full policy PDF