| Policy Title | Patient Safety Incident Response Framework Policy |
| Policy Author/Reviewer | Sharon Giles |
| Version Number | 1.0 |
| Version Publication Date | 26.06.2025 |
| Next Review Date | 26.06.2026 |
Amendment History
| Version Issue | Date of change | Reasons for change | Date |
| 2 | 15.8.25 | Amendments suggested by PSIRF team | 15.8.25 |
| SECTION | CONTENTS | PAGES |
| 1 | Policy Statement | 3 |
| 2 | Purpose & Scope | 3-4 |
| 3 | Definitions | 4 |
| 4 | Our Patient Safety Culture | 4-5 |
| 5 | Patient Safety Partners | 5 |
| 6 | Addressing Health Inequalities | 5 |
| 7.0 7.1 7.2 | Engaging and Involving Patients and Staff Following a Patient Safety Incident Patients Staff | 5-6 |
| 8 | Patient Safety Incident Response Planning | 6 |
| 9 9.1 9.2 9.3 9.4 9.5 | Responding to Patient Safety Incidents Patient Safety Incident Reporting Arrangements Responding to Cross-System Incidents/Issues Timeframes for Learning Responses Safety Action Development and Monitoring Improvement Safety Improvement Plans | 7-8 |
| 10 | Oversight Roles and Responsibilities | 8 |
| 11 | Concerns and Complaints | 8 |
1. Policy Statement
The NHS Patient Safety Strategy was published in 2019 and describes the Patient Safety
Incident Response Framework (PSIRF), which replaces the NHS Serious Incident
Framework (SIF). PSIRF sets out a new approach to learning and improving following patient safety incidents across the NHS in England. Compassionate engagement and involvement of those affected by patient safety incidents is central to the PSIRF approach. Axminster Medical Practice (AMP) is required to implement these PSIRF principles as an independent provider contracted under the NHS standard contract.
2. Purpose & Scope
This policy supports the requirements of the PSIRF and sets out AMP’s approach in developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety, and that integrates the four key aims of the PSIRF:
- compassionate engagement and involvement of those affected by patient safety incidents
- application of a range of system-based approaches to learning from patient safety incidents
- considered and proportionate responses to patient safety incidents and safety issues
- supportive oversight focused on strengthening response system functioning and improvement.
The PSIRF advocates a co-ordinated and collaborative response to patient safety incidents. It embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management. This policy is specific to patient safety incident responses conducted solely for the purpose of learning and improvement at AMP.
Responses under this policy follow a systems-based approach. This recognises that patient safety is an emergent property of the healthcare system: that is, safety is provided by interactions between components and not from a single point of blame. 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.
There is no remit to apportion blame or determine liability, preventability or cause of Death in a response conducted for the purpose of learning and improvement. Other processes, such as non-patient safety complaints, human resources investigations into employment concerns, professional standards investigations, coronial inquests and criminal investigations, exist for that purpose. The principle aims of each of these responses differ from those of a patient safety response and are outside the scope of this policy.
Information from a patient safety response process can be shared with those leading other types of responses, but other processes should not influence the remit of a patient safety incident response.
This policy is written in accordance with:
o The Care Quality Commission (CQC) ‘Guidance for Providers on Meeting the
Regulations’, Regulation 20 (Duty of Candour) and Regulation 12 (Safe Care and
Treatment)
o The Health and Safety Act 1974, Reporting of Injuries, Disease and Dangerous
Occurrences Regulation 1995 (RIDDOR)
o Patient Safety Incident Response Framework (PSIRF) and Tools
3. Definitions
Patient Safety Incident (PSI) – Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm.
Patient Safety Incident Investigation (PSII): is undertaken when an incident indicates significant patient safety risks and potential for new learning. The purpose is to identify what happened and why, so that we can try and reduce the chances of it happening again.
We will look at the circumstances that led to the incident, and review procedures and practices using a systems-based approach, to identify areas that need to be changed or improved.
Significant Event Analysis (SEA): is a method of evaluation that is used when outcomes of an activity or event have been particularly successful or unsuccessful. It aims to capture learning from these to identify the opportunities to improve and increase to occasions where success occurs. These findings are shared with the whole practice team at a quarterly meeting for all staff with the aim of reducing the risk of the same thing happening in future.
4. Our Patient Safety Culture
AMP is an organisation which embeds its core values to promote an open and transparent culture around patient safety, incident reporting and learning.
AMP fosters a ‘just culture’ approach and understands that creating an environment where colleagues feel able to report incidents and raise concerns without fear of recrimination, is essential to improving safety. We encourage and support incident/event reporting where any member of staff feels something has happened, or may happen, which has led to, or may lead to, harm to patients, family, employees, service and reputation.
AMP uses GP Teamnet as our electronic incident reporting system, and a transparent and robust incident reporting culture is promoted across all teams. Incidents are reviewed immediately by those involved and their team leader or senior clinician and then discussed with all staff at our quarterly Significant Event Analysis meeting.
During this meeting proportionate and appropriate learning responses are allocated to each incident, focusing on maximising learning. AMP work hard to create a resilient workforce who are encouraged to reflect on incidents and participate in these quarterly meetings which helps develop learning outcomes.
At AMP we want our teams to feel respected and valued and to know that we welcome their views, suggestions and concerns.
However, should they feel they cannot speak to anyone in the Practice they are advised to contact the National Freedom to Speak Up Guardians service. In addition, staff complete Freedom To Speak Up training by way of an E-Learning module.
5. Patient Safety Partners
The Patient Safety Partners (PSP) is a new and evolving role developed by NHSE to help improve patient safety across the NHS.
This is a role which AMP is keen to develop as we recognise the benefits of having PSP perspectives and involvement in all aspects of improving our organisation’s patient safety. It is envisaged that this may include contribution to documentation including policies and plans. We see this role initially being fulfilled within our PCN and the PCN governance team have regular fortnightly Governance meetings, to ensure that patient safety is at the forefront of everything we do.
We also have an active PPG who hold quarterly meetings at which we hear firsthand about patient experience with the Practice and can discuss any issues raised.
6. Addressing Health Inequalities
AMP is committed to reducing health inequalities by improving access to healthcare for all, but particularly those identified by Population Health Management as having additional needs and reasonable adjustments. We value diversity and promote a culture of respect for all.
We wish for all aspects of our service to be accessible and inclusive for patient under our care, regardless of their background or circumstances.
We will work to identify any potential inclusivity issues and where required we will ensure that available tools such as translation and interpretation services are accessed to support the needs of those involved in incidents/investigations
7.0 Engaging and Involving Patients and Staff Following a Patient Safety Incident
The PSIRF recognises that learning and improvement following a patient safety incident can only be achieved if there are supportive systems and processes in place. It supports the existing process of an effective patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents, including patients and staff. This involves working with those affected to understand and answer any questions they have in relation to the incident, and signpost them to support as required.
7.1 Patients:
When an incident occurs, or something goes differently to how we expected/intended or where concerns are raised, our patient safety culture recognises the importance of involving the patients, if appropriate, involved at the earliest opportunity. This can contribute to minimising harm and maximising learning, whilst transparency and honesty encourage confidence in our service.
Where concerns or complaints are raised, we aspire to resolve and learn from these in a timely manner, ensuring that individuals are listened to and engagement is compassionate and respectful.
Our staff understand their responsibility and accountability in reporting incidents and informing those involved if an error has occurred. Apologies are meaningful and saying sorry does not mean admitting blame when something goes wrong.
In addition to meeting our professional and regulatory requirements for Duty of Candour, at AMP we want to be open and transparent with the population we care for regardless of the level of harm caused by an incident. This is why our first response is always to inform those involved, if appropriate, and work with them in our learning responses.
7.2 Staff:
Involving the staff involved in patient safety incidents in a compassionate way is a fundamental part of our patient safety culture. This is done by involving specifically involved staff members in any incident investigation so that they can gain a more in depth understanding of what happened to try and ensure something similar does not happen again. Incidents are also anonymously discussed with all staff at our quarterly Significant Event Analysis meetings so that we can gain insight and input from a wider perspective into how we could improve things.
PSIRF does not seek to apportion blame but is a route to identifying learning and areas for improvement. Engagement with those involved is key to development of systems which enhance patient safety.
We are committed to creating a no blame culture and have redefined our Significant Event Analysis reporting structure and process to reflect this and create an environment which encourages participation and a collaborative approach.
Our staff are fully trained and aware of safeguarding protocols and the Learning Disabilities Mortality Review (LeDeR) process. They are equipped to identify any relevant concerns and know how to make appropriate referrals to ensure the safety and well-being of our patients.
8.0 Patient Safety Incident Response Planning
The PSIRF supports organisations to respond to incidents and safety issues in a way that maximises learning and improvement, rather than basing responses on arbitrary and subjective definitions of harm. Beyond nationally set requirements, organisations can explore patient safety incidents relevant to their context and the populations they serve rather than only those that meet a certain defined threshold.
AMP is committed to fully embedding PSIRF and ensuring that all care team members actively contribute to our organisation meeting its requirements.
Training for staff varies depending on their role but every staff member within AMP is expected to have a basic understanding of patient safety event recognition, reporting and candour.
- All Staff including Health & Safety, facilities and Senior management team (SMT) are required to have completed:
- Level 1 -Essentials of patient safety which is available via our e-learning on Practice Index.
- All Clinicians and the Management Team are required to have completed (in addition to level 1):
- Level 2- Patient Safety Syllabus from ELfH which is available via our e-learning on Practice Index.
9.0 Responding to Patient Safety Incidents
9.1 Patient Safety Incident Reporting Arrangements
All staff are responsible for reporting any actual or potential patient safety incidents via GP Teamnet, our electronic reporting system.
We are committed to ensuring that staff have the time and capacity to respond to patient safety incidents in the moment, providing immediate action and reporting incidents as soon as practicable to enable the review and appropriate learning responses to begin in a timely way.
The framework in place provides a process for escalation and a robust system of support for all those involved in patient safety incidents.
The Patient Safety Lead is automatically alerted of all incidents via email.
Any incidents which require reporting externally are overseen by the Patient Safety Lead and the Senior Management GP Partner. Where incidents meet the national requirement for PSII we will work transparently and collaboratively with our ICB.
As encouraged by our ICB we will report all relevant Patient Safety Incidents to the NHS Learning from Patient Safety Events (LFPSE) portal.
9.2 Responding to Cross-System Incidents/Issues
Where an incident occurs which involves multi-organisational and cross system working, AMP are committed to involving, working with, and learning from all organisations involved. Collaboration with external organisations will bring diverse perspectives and will help create innovative solutions and enhance learning.
Learning from incidents is paramount for continuous improvement, and sharing incident information and insight with other organisations encourages a transparent and open culture which maximises learning. To that end all learning will be shared via LfPSE and across our PCN.
At AMP we have close working relationships with the community teams, and other Practices in our PCN with whom we work.
We will ensure that we raise all cross-system incidents within our own incident reporting module and will include the actions and learning gathered from other organisations involved in our review of the incident.
9.3 Timeframes for Learning Responses
Learning responses begin as soon as possible after any incident occurs. Timeframes for completion will be agreed in discussion with those affected by an incident. A balance between conducting a thorough review and not delaying actions which may impact safety will be sought.
We will seek to complete all learning responses within one to three months and completion of PSII should not exceed six months. Where a longer timeframe may be required this will be communicated and discussed with those affected.
9.4 Safety Action Development and Monitoring Improvement
At AMP we understand that patient safety learning responses are the key to understanding the circumstances surrounding incidents, but this may only be the beginning. Robust safety actions and improvement plans actions are required to successfully reduce risk and improve patient safety.
9.5 Safety Improvement Plans
There are no thresholds for when a safety improvement plan should be developed. We will take a SMART approach to our safety improvement planning to ensure that actions are Specific, Measurable, Attainable, Relevant and Time-scaled.
10. Oversight Roles and Responsibilities
Oversight of the PSIRF will be maintained by the management team. We will share Patient Safety Incidents and examples of good care with NHSE via Learning From Patient Safety Events (LFPSE), and with our ICB.
Managers are responsible for:
- Ensuring that all incidents that occur are reported in a timely manner and in accordance with the Practice Policies and Procedures.
- Identifying causes of incidents and putting in place measures to minimise the likelihood of recurrence by establishing any lessons to be learnt and implementing these locally.
- Informing their staff of any lessons to be shared both internally and externally.
All AMP Staff are responsible for:
- Reporting incidents and near misses promptly.
- If a witness to or directly involved in an incident, addressing the immediate health needs of the person(s) involved in an incident, ensuring that the situation is made safe, informing their manager, and completing an incident on GP Teamnet.
- Undertaking immediate action to manage the incident and identifying actions needed to minimise the chances of recurrence.
- Engaging in the investigation of incidents and providing information where required
11. Complaints and Concerns
Any concerns or complaints raised relating to AMP’s response to patient safety incidents will be dealt with in line with the organisation’s complaints procedure. We will seek to work with those affected and involved to resolve issues where possible, maximise learning and improve our service.
If a patient has a concern or complaint they can raise this via our website www.axminstermedicalpractice.nhs.uk and click on ‘Have Your Say’ – here is a link https://www.axminstermedicalpractice.nhs.uk/about-us/practice-policies/patient-rights/complaints/
Alternatively, the patient can write to the Practice Manager at the surgery with any concerns or complaints they may have. All complaints/concerns are dealt with per the timescales shown on the complaints page of our website. However, we endeavour to respond to all complaints promptly and before these time scales.