The 2015 Serious Incident Framework set the expectations for when and how the NHS should investigate Serious Incidents. However, compelling evidence from national reviews, patients, families, carers and staff and an engagement programme in 2018 revealed that organisations struggle to deliver these.
While recognising the importance of learning from what goes well, identifying incidents, recognising the needs of those affected, undertaking meaningful analysis and responding to reduce the risk of recurrence remain essential to improving safety. Doing this well requires the right skills, systems, processes and behaviours throughout the healthcare system.
The PSIRF will support the NHS to operate systems, underpinned by behaviours, decisions and actions, that assist learning and improvement, and allow organisations to examine incidents openly without fear of inappropriate sanction, support those affected and improve services.
The PSIRF proposals explore:
- A broader scope: describing principles, systems, processes, skills and behaviours for incident management as part of a broader system approach, providing and signposting guidance and support for preparing for and responding to patient safety incidents in a range of ways, moving away from a focus on current thresholds for ‘Serious Incidents’.
- Transparency and support for those affected: setting expectations for informing, involving and supporting patients, families, carers and staff affected by patient safety incidents.
- A risk-based approach: we think organisations should develop a patient safety incident review and investigation strategy to allow them to use a range of proportionate and effective learning responses to incidents. The proposal is to explore basing the selection of incidents for investigation on the opportunity they give for learning; and ensuring that providers allocate sufficient local resources to implement improvements that address investigation findings.
- Purpose: reinforcing the purpose of patient safety investigation and insulating it against scope creep and inappropriate use, so that safety investigations are no longer asked to judge ‘avoidability’, predictability, liability, fitness to practise or cause of death.
- Governance and oversight: taking a different approach to the oversight and assurance provided by commissioners, emphasising instead the role of provider boards and leaders in overseeing individual investigations.
- Terminology: making references to ‘systems-based patient safety investigation’, not ‘root cause analysis’, to reflect the ‘systems’ approach to safety.
- Timeframes: instead of applying a strict 60 working day deadline, adopting timeframes based on an investigation management plan that is agreed where possible with those affected, particularly patients, families and carers.
- Investigation standards and templates: introducing national standards and standard report templates.
- Investigator time and expertise: requiring investigations to be led by those with safety investigation training and expertise, and with dedicated time and resource to complete the work.
- Cross-setting investigation and regionally commissioned investigation: to better reflect the patient experience, co-ordination of investigation across multiple settings will be supported. This will include clearer roles and responsibilities for NHS regional teams to support investigation of complex cross-system incidents where needed.