How to Implement PSIRF

Successfully implementing the Patient Safety Incident Response Framework (PSIRF) requires a planned, phased approach. NHS-funded organisations across England are encouraged to adopt PSIRF in line with NHS England’s guidance, ensuring they are fully prepared to embed its principles into their governance and daily practice.

This section provides an overview of how healthcare providers can transition to PSIRF, including what’s required to prepare, develop a compliant Patient Safety Incident Response Plan (PSIRP), and ensure staff are trained and supported throughout the process.

‍Preparing for PSIRF

‍Before adopting PSIRF formally, organisations need to complete a comprehensive preparation and diagnostic phase to understand their current state and readiness. NHS England has outlined key preparatory actions to support this process.

‍Preparation includes:
• Understanding PSIRF’s core principles and securing executive-level sponsorship.
• Conducting a baseline diagnostic to assess current systems, culture, and capability.
• Reviewing and strengthening governance structures, particularly around patient safety oversight.
• Planning for appropriate resource allocation, including dedicated roles in patient safety and investigations.

The outcome of this phase is a clear picture of how ready the organisation is to adopt PSIRF and where further development is needed.

‍Developing a Patient Safety Incident Response Plan (PSIRP)

‍A critical step in implementation is the creation of a Patient Safety Incident Response Plan (PSIRP). This is a strategic document that outlines how your organisation will respond to incidents in a way that aligns with PSIRF principles.

A PSIRP must include:
• The organisation’s prioritised incident types or themes for learning response activities.
• A rationale for why those priorities were selected, based on local data and national insight.
• Details of investigative methods and approaches to be used (e.g. SEIPS, FRAM).
• A process for involving patients, families, and staff in investigations.
• Oversight mechanisms to monitor learning outcomes and continuous improvement.

The PSIRP is not static – it should be reviewed and refined at least annually, or whenever significant changes in service or risk landscape occur.

‍Tools and Templates

‍To support a smooth transition, NHS England provides a suite of PSIRF tools, templates, and guidance documents. These resources are designed to streamline implementation and ensure national consistency, while allowing for local flexibility.

Key resources include:
• PSIRF Preparation Guide – a step-by-step roadmap for adopting the framework.
• PSIRP Development Template – a structured format for drafting and reviewing your plan.
• Engagement and Involvement Guidance – for involving patients and families in learning responses.
• Oversight Roles and Responsibilities Specification – for effective governance.
• Proportionality Guidance – to help tailor responses to incident complexity.

You can access these directly from the NHS England website.

‍Training and Support

‍Effective PSIRF implementation depends on equipping staff with the knowledge, confidence, and tools to carry out learning responses and investigations in line with the new framework.

Organisations should prioritise:
• Training for safety and quality teams, investigators, and clinical leaders on:
– Systems thinking
– Human factors and ergonomics
– Trauma-informed engagement

• Establishing a learning and development plan for ongoing staff education.
• Accessing national PSIRF webinars, workshops, and NHS England-hosted learning events.
• Joining patient safety networks and forums for peer support and shared learning.

Internal communications should reinforce the message that PSIRF is about culture change, not just new processes.