Patient Safety Incident Response Framework (PSIRF)
What is the Patient Safety Incident Response Framework (PSIRF)?
A patient safety incident is when something goes wrong in a patient’s care or treatment that causes them harm, or that has the potential to cause harm. The Patient Safety Incident Response Framework sets out our approach to responding to patient safety incidents. This includes how we learn from incidents and work to improve the safety of people who access our services.
The main aims of the PSIRF are:
- To make sure that people who are affected by patient safety incidents are treated with compassion and are meaningfully involved.
- To learn from patient safety incidents so that we can prevent things from going wrong in the future and keep people as safe as we can.
- To respond to patient safety incidents and safety issues appropriately.
- To improve how we respond to patient safety incidents.
Our PSIRF policy outlines what we will do and our plan details how we will do it. They apply to all the services we provide across England. We are committed to continually improving our patient safety culture and to being open and transparent. We will carry out regular reviews of our policy and plan so that we remain flexible and responsive to learning and to the needs of people who access our services and their families and friends.
How PSIRF links to our organisational aims
Our mission is to lead the way to a better quality of life for all people severely affected by mental illness. Our Communities that Care Strategy sets out how we plan to achieve this. We want to improve the quality of care that people receive at a national and local level. We work in partnership with others to deliver support and services that people need. Regardless of a person’s situation we will always take a person centred approach and ensure that people’s rights are upheld.
We are committed to involving people with lived experience and carers in all aspects of our work. This includes involving people in their care, in shaping our services and informing our patient safety responses and plans. We will involve people with lived experience and carers in regular reviews of our policy and plan to ensure that our responses are shaped by the people we seek to serve.
Our values of hope, understanding, expertise, commitment, passion and openness underpin everything we seek to achieve. We put equity (or fairness) at the heart of everything we do and have made a firm commitment to becoming an anti-racist organisation and to tackling all forms of discrimination and inequality. Our patient safety incident response processes proactively address health inequalities by identifying if there is any disproportionate risk to people with specific characteristics who access our services.
Confidentiality
We will comply with the UK GDPR and Data Protection Act 2018 and take great care to preserve the privacy of and safeguard any personal information provided to us. We will be clear with those involved in a patient safety incident about how their information will be used and those it will be shared with. Confidentiality will be maintained where possible. For further information on how we process personal data, refer to our Privacy Policy.
Duty of Candour
We have a legal responsibility to be open and transparent with people receiving care from our services, including when things go wrong. This is known as the ‘duty of candour’.
Our engagement principles
The NHS framework has developed engagement principles to guide what you can expect from us if something does go wrong. Using these principles, we commit to:
1. Ensure that our apologies are meaningful
2. Take into account people’s individual needs
3. Be sensitive to the timing and timescales of any response
4. Treat people who are affected with respect and compassion
5. Offer clarity and guidance
6. Make sure that people affected are listened to and heard
7. Collaborate with you, with openness and transparency
8. Understand that people’s feelings are subjective and that we all feel and experience things differently
9. Strive for equity
Our response to incidents
When there is a patient safety incident we carry out an investigation so that we can learn and better understand what factors might have led to the incident. This helps us to prevent this from re-occurring and keep people as safe as possible.
When carrying out investigations we balance the need to be as swift as possible for all involved, whilst making sure that the investigation is thorough. Our aim is to identify the key factors that might have led to the incident so that we can learn and improve.
The investigation process is as follows:
Initial investigation – we carry out an initial investigation within 5 working days of an incident being reported. This is so that the incident is still fresh in people’s minds to help us gather complete and accurate information.
Full investigation – the full investigation will be completed within 30 to 60 days. How long an investigation takes can depend on the complexity of the situation and incident.
Click here to see our Patient Safety Incident Response Infographic.
Safety improvement plans
We have developed a Patient Safety Incident Response Plan which details our improvement priorities.
The improvement priorities (themes) have been informed by a range of data and information, for example from audits we have carried out into our services, safeguarding investigations, whistleblowing investigations, deaths of people who have accessed our services, complaints and Human Resources investigations.
For each theme, the plan will determine the key drivers to patient safety risks, how improvements can be made and how these can be monitored so that we effectively achieve what we say we will. Whilst the plan identifies the broad priorities, we know there may be more specific ones and improvements at a local service level which will not form part of the overarching plan, but can still be addressed using the PSIRF approach.
Oversight roles and responsibilities
Rethink is governed by a Board of Trustees, a group of individuals who have overall responsibility for the management and governance of an organisation. Oversight of the PSIRF sits with our Board of Trustees. They have directed the Audit and Assurance Committee to hold responsibility for effective monitoring and oversight of PSIRF.
We are committed to close partnership working with the relevant local Integrated Care Boards (ICBs) to ensure oversight and provide assurance that improvements and priorities under PSIRF are progressing and improvements in quality and safety are being delivered.
Complaints and appeals
Any complaints relating to our PSIRF approach can be raised via the Complaints process.