Services
Patient Safety and Incident Learning
I help organisations move beyond incident reporting to meaningful learning and improvement.
Talk it through
I offer a complimentary 30-minute introductory consultation to understand your organisation, your priorities and where I may be able to help.
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What support can include
- Patient safety incident investigation
- PSIRF implementation
- Learning from incidents
- Action planning
- Human factors and systems thinking
- Incident review processes
- Patient safety improvement
- Learning dissemination
CQC regulation
20
Duty of candour
A legal requirement to be open and transparent with people about their care. After a notifiable safety incident, that includes telling them and apologising.
Questions this can help you answer
- Do our incident reports lead to learning and action?
- Are the actions from incident reviews being followed up?
- Can our staff see what changed because of an incident?
- Do we know where we stand with PSIRF?
Who this suits
- Community services
- Care homes and adult social care
- Dental practices
- NHS trusts and ICB/ICS organisations
What is PSIRF?
PSIRF is the Patient Safety Incident Response Framework, the NHS's approach to responding to patient safety incidents so that organisations can learn from them and improve patient safety. It replaced the Serious Incident Framework (2015) and makes no distinction between patient safety incidents and serious incidents.
It is not an investigation framework that prescribes what to investigate. Instead, an organisation plans a proportionate response and sets it out in a patient safety incident response policy and plan.
Duty of candour
Registered providers must act in an open and transparent way with people about their care and treatment (Regulation 20).
After a notifiable safety incident this includes telling the person as soon as reasonably practicable, apologising, and giving reasonable support.
How I approach it
Finding
An incident, or a pattern across incidents, is identified and understood.
Action
Actions are agreed that look at how the system allowed it to happen, not only who was involved.
Evidence
Evidence that the actions were completed and made a difference.
Sign-off
The actions are reviewed and closed by the people responsible.
Sustained improvement
The learning is shared and checked again so it is not lost.
Common questions
What is the difference between reporting an incident and learning from it?
Reporting records what happened. Learning means the incident leads to action, the action is followed up, and what was learned is shared so the change lasts.
Do you help with PSIRF?
Yes. Support can include PSIRF implementation and patient safety incident investigation, as well as incident review processes and learning dissemination.
How do you make learning visible to staff?
Learning only helps if staff can see it. I help organisations share what they have learned from incidents and show what changed as a result, so that it becomes part of everyday practice.
Start with a conversation
I take on a limited number of engagements at a time, so each organisation receives my full attention. If you are considering support, an early conversation is the best way to talk about timing.
The experience behind my patient safety work is set out on its own page.
Book a Complimentary 30-Minute Consultation