PSIRF in Practice

Implementing the Patient Safety Incident Response Framework (PSIRF) involves more than updating policies – it requires organisations to adopt new ways of thinking, responding, and learning from patient safety events.

This section provides insight into how PSIRF works in real-world healthcare settings, including the types of responses used, how it differs from legacy methods like Root Cause Analysis (RCA), and how it integrates with existing digital systems.

‍Examples of Response Types

‍Under PSIRF, not every patient safety incident requires the same type of investigation. Instead, healthcare providers are encouraged to use a variety of evidence-based, proportionate response methods tailored to the complexity and potential for learning from each event.

‍Common response types under PSIRF include:
‍
After Action Review (AAR): A facilitated, team-based reflective process used shortly after an event. It helps staff openly discuss what happened, why it happened, and what can be improved.

Learning Response: A flexible investigative approach focusing on understanding the factors contributing to an incident, especially where system-level insights are needed.

Thematic Review: Used when similar types of incidents are occurring frequently, allowing teams to examine trends and systemic causes.

Case-based Reflection or Debrief: Informal yet structured team discussions, typically used in lower-harm or near-miss situations.

These approaches are adaptable, inclusive, and focused on systems thinking. They ensure that the primary outcome is meaningful learning, not assigning blame.

‍How PSIRF Differs from Root Cause Analysis (RCA)

‍A key part of understanding PSIRF is recognising how it moves away from traditional Root Cause Analysis (RCA). While RCA was the default method for incident investigation under the previous Serious Incident Framework, it has been widely criticised for its limitations.

‍Key differences include:‍