System Safety

Patient safety systems are a fundamental foundation of the NHS patient safety strategy. Each of the many organisations that make up the English healthcare system (both NHS and non-NHS) has its own remit and responsibility for improving patient safety.

Hospitals, general practices and other providers are responsible for the safety of their patients and sharing local information about risks and best practice. Patient safety is supported from neighbourhood and place to system to ensure the provision of safe care and help to tackle problems that cut across care settings.

With primary care (community pharmacy, dental services, general practice and optometry) encompassing over 90% of all NHS consultations, there remains a huge opportunity to understand more and to further improve patient safety in new and innovative ways in this area.

Overview

We have been working across primary care to identify areas for improvement and co-design solutions to promote incident recording via the learn from patient safety events service (LFPSE) and exploring how to implement the Patient Safety Incident Response Framework (PSIRF) to improve sharing and learning of safety themes.

The Patient Safety team of NHS England commissioned the Health Innovation Network South London to support the launch of a pilot implementing PSIRF in general practice on a national level. You can read more about PSIRF and the PSIRF in General Practice pilot programmes below.

Patient Safety Incident Response Framework (PSIRF)

NHS England has published the new Patient Safety Incident Response Framework (PSIRF) outlining how NHS organisations should respond to patient safety incidents for the purpose of learning and improvement.

The framework will replace the current Serious Incident Response Framework by Autumn 2023 and represents a significant shift in the way the NHS responds to patient safety incidents, centring on compassion and involving those affected; system based approaches to learning and improvement; considered and proportionate responses; and supportive oversight.

PSIRF is a major step towards improving safety management across the healthcare system in England and will greatly support the NHS to embed the key principles of a patient safety culture. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals; allowing for more effective learning and improvement, and ultimately making NHS care safer for patients.

Find out more about PSIRF on the NHS England website.

Patient Safety Collaboratives have been commissioned to support the national adoption and scale up of PSIRF with fidelity to core principles, working in collaboration with partners in NHS England’s regional teams. Our offer will include supporting the learning and sharing as organisations go through the preparation period ahead of transition from their existing Serious Incident Framework to PSIRF. We are also working to support the emerging patient safety structures within systems as well as connecting to relevant regional and national networks.