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This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin transitioning to the PSIRF from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement.
The NHS has systems to support the reporting of safety incidents and from these reports it learns how to make healthcare safer. However, despite these efforts and the continuing advances in patient care, the inherent risks and complexity of healthcare mean an NHS entirely free of incidents is an unrealistic expectation. Identifying incidents, recognising the needs of those affected, examining what happened to understand the causes and responding with action to mitigate risks remain essential to improving the safety of healthcare. Creating systems that do this is a complex, challenging and continuous endeavour that requires the right skills, processes and – perhaps most importantly – behaviours. We know that organisations are struggling to deliver good quality investigations that consistently support the reduction of risk. As a result, opportunities to reduce patient safety incidents can be missed.
“Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2022.”
“To support the NHS to further improve patient safety, we are preparing for the introduction of a new Patient Safety Incident Response Framework (PSIRF), outlining how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.”
“This introductory Patient Safety Incident Response Framework responds to calls for a new approach to incident management, one which facilitates inquisitive examination of a wider range of patient safety incidents “in the spirit of reflection and learning” rather than as part of a “framework of accountability”. Informed by feedback and drawing on good practice from healthcare and other sectors, it supports a systematic, compassionate and proficient response to patient safety incidents; anchored in the principles of openness, fair accountability, learning and continuous improvement.
This conference will enable you to:
- Network with colleagues who are working to improve the investigation of serious incidents
- Ensure your approach to Serious Incident Investigation is in line with the NHS Patient Safety Strategy
- Update your knowledge with national developments including the New Patient Safety Incident Response Framework
- Understand developments in the PSIRF early adopter sites
- Reflect on the management and investigation of serious incidents involving Covid-19
- Learn from outstanding practice in the development of serious incident investigation and mortality review
- Reflect on the perspectives of a patient who has been involved in a serious incident
- Develop a risk based response to incident investigation
- Reflect on the development of mortality governance within your organization and understand the challenges of Covid-19
- Understand how to work with staff to ensure a focus on learning and continuous improvement
- Develop your skills in Serious Incident Investigation: applying the human factors to move the focus of investigation from acts or omissions
- of staff, to identifying systems improvement
- Identify key strategies for improving investigation of serious incidents
- Gain CPD accreditation points contributing to professional development and revalidation evidence