Strengthening patient safety through system-wide learning: Patient Safety Incident Response Framework
Health Innovation South West is supporting the implementation of the Patient Safety Incident Response Framework (PSIRF), a system-based approach to learning from patient safety incidents, across healthcare providers in the region.
Impact
- 50% increase in attendance at the Devon & Cornwall Patient Safety Specialist (PSS) Network relaunch.
- Pilot of PSIRF Maturity Assessment Tool across seven providers in the South West and one West of England ICB.
- Primary Care engagement through collaboration with national Health Innovation Network GP leads to bring PSIRF learning into general practice.
- United 18 Patient Safety Specialists and ICB leads in an in-person workshop enhancing collaboration and engagement. Revised ToRs and planned commitment for collaboration for the next year.
- United 56 attendees from across the southwest system at an in-person PSIRF Maturity Matrix event.
- Partnerships with HSIBB: Ensuring 24 system colleagues receive specialist training in SEIPS tools and approaches, boosting system capability in learning from patient safety incidents.
Project summary
The Patient Safety Incident Response Framework (PSIRF) aims to address the challenge of improving incident management and patient safety by providing a structured process and tool for organisations to baseline their practices, identify areas for improvement, and foster collaboration.
Patients, families, healthcare providers and staff all benefit from improved engagement, structured learning and cultural change.
Health Innovation South West has facilitated collaboration and knowledge sharing with Integrated Care Boards and providers, helped the spread of ideas and supported key relationships, which were essential for effective healthcare delivery, patient safety and improvement.
A key achievement includes the pilot of a PSIRF Maturity Matrix in collaboration with ASW Assurance, which has enabled participating organisations to assess and improve their safety systems. This collaborative model is now supporting the sharing of best practice regionally and contributing to national safety goals.
Rationale
This project addresses inconsistent and silo approaches to incident response and oversight.
Many providers lack clarity on what effective PSIRF implementation looks like and how to measure progress. By introducing the PSIRF Maturity Matrix and facilitating collaborative learning, this project helps build a fair, open culture that supports meaningful learning from incidents.
The initiative strengthens assurance at system level and supports the NHS shift from reactive response to proactive safety improvement.
Key stakeholders
- Health Innovation South West designed, launched, funded and coordinated the project, including evaluation delivery and innovator support.
- Innovation partners: Lucida Medical, Gentle Recovery and MySunrise deliver and support the deployment of digital tools.
- Delivery partners: NHS Trusts including Somerset NHS Foundation Trust and Torbay and South Devon NHS Foundation Trust enable clinical access and real-world implementation.
Next steps
Evaluation results are due in June 2025 and will inform:
- Business cases for scale and spread.
- Engagement with ICBs for adoption planning.
- Identification of further innovation needs in cancer care.
Opportunities remain open for additional trusts and systems to test or adopt these tools, and from partners who can support spread and scale.
