Key Principles of PSIRF

‍The Patient Safety Incident Response Framework is underpinned by four foundational principles that guide how NHS organisations and healthcare providers investigate, learn from, and respond to patient safety incidents. These principles represent a cultural and operational shift – moving away from blame and towards learning, improvement, and person-centred care.

1. Compassionate Engagement and Involvement of Those Affected

‍A core aim of PSIRF is the meaningful and compassionate engagement of patients, families, carers, and staff affected by safety incidents. It acknowledges the emotional impact of these events and seeks to ensure that those involved are treated with empathy, respect, and transparency.

Organisations are expected to:
• Provide clear, timely, and trauma-informed communication throughout the incident response process.
• Involve patients and families in shaping the focus of investigations where appropriate.
• Honour the Duty of Candour not just as a regulatory requirement, but as a foundation for trust and accountability.

This principle strengthens relationships between providers and the public and ensures that investigations are more inclusive and insightful.

‍2. Application of a Range of System-Based Approaches to Learning

‍PSIRF encourages healthcare organisations to adopt a variety of system-based investigative methods, moving away from one-size-fits-all models like Root Cause Analysis (RCA). This enables a deeper exploration of the underlying system factors that contribute to incidents.

Key elements include:
• Using evidence-based tools such as:
– Systems Engineering Initiative for Patient Safety (SEIPS)
– Functional Resonance Analysis Method (FRAM)
– Human Factors Analysis and Classification System (HFACS)

• Exploring interactions between people, processes, technology, and environments.
• Understanding how real-world conditions impact clinical decision-making and performance.

These approaches generate more robust, actionable learning that leads to lasting safety improvements.

‍3. Considered and Proportionate Responses to Patient Safety Incidents

‍PSIRF promotes a measured, risk-based approach to responding to safety incidents, ensuring resources are deployed proportionately and learning is prioritised where it will have the most value.

In practice, this means:
• Using structured decision-making tools to assess the appropriate level of response.
• Prioritising investigations based on factors such as harm severity, recurrence risk, and organisational impact.
• Applying diverse response types, such as:
– After Action Reviews
– Learning Responses
– Thematic Reviews
– Case-Based Reflections

By tailoring the response to each incident, organisations can avoid unnecessary investigations and focus on areas with the highest learning potential.

‍4. Supportive Oversight Focused on Strengthening System Functioning

‍Oversight in PSIRF is not about performance management or assigning blame – it is about supporting continuous improvement in how organisations learn and respond to safety events. Governance structures should enable reflection, accountability, and resilience.
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This includes:
• Establishing clear oversight roles at executive and board levels.
• Monitoring the function and maturity of incident response systems.
• Reviewing investigation outcomes and learning integration as part of quality governance processes.

Supportive oversight enables organisations to improve not just how they investigate, but how they learn, adapt, and evolve their patient safety culture over time.

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