At NHS Dorset, the Patient Safety and Risk team works to improve patient and service safety and minimise risk.

The team:

  • oversees provider patient safety incidents, and how they respond to them

  • identifies themes and trends in provider incident data

  • helps providers share their learning with each other and with the rest of the country

  • supports providers with everything related to patient safety.

Patient Safety Incident Response Framework

The Patient Safety Incident Response Framework (PSIRF) sets out how the NHS responds to incidents. It focuses on understanding how incidents happen instead of looking at who is to blame. This means more effective learning for staff, and safer care for patients.

This framework replaces the Serious Incident Framework (2015) and is a key part of the NHS Patient Safety Strategy.

Based on existing local improvement work, the PSIRF can help organisations develop a patient safety incident response policy and plan. It can also help them work out where a patient safety incident response would help most.

It also removes the requirement that only ‘serious’ incidents are investigated.

This means:

  • more focus on areas with the greatest potential for improvements

  • important learning from incidents not classed as ‘serious’.

Guide to engaging and involving patients, families and staff following a patient safety incident document

This document was published alongside the PSIRF. It says anyone affected by an incident (for example patients, families, and staff):

  • should be treated with compassion

  • should be involved in any investigation process.

Resources

Find out more about the Patient Safety Incident Response Framework, and how we are using it in Dorset.

Learn from patient safety events

A new national NHS service for recording and analysing patient safety events. It helps improve the learning gathered from patient safety incidents, making care safer.

How LFPSE will improve patient safety learning

Patient safety and risk training

NHS England has published the first NHS-wide patient safety syllabus, available to all NHS employees. It will result in better patient safety training for all staff.

The training outlines the NHS’s approach to patient safety.

Level 1 – Essentials for patient safety

All NHS staff encouraged to complete this level.

Also provides a session for senior leaders – Essentials of patient safety for boards and senior leadership teams.

Level 2 – Essentials for patient safety

For people who want to learn more about patient safety and/or access the higher levels of training.

Levels 3 and 4

Intended for people identified as patient safety specialists (PSS) at their trusts. In the future other staff working on patient safety may also be able to complete these levels.

Level 5

For patient safety experts. Ideal for innovators and leaders in this area who want to build on the skills developed in levels 3 and 4.

Medical examiners

Medical examiners are senior doctors who provide independent scrutiny of causes of death. They do this outside of their usual clinical work, and are trained in the legal and clinical elements of the death certification process.

Medical examiner system

The medical examiner system:

  • ensures independent scrutiny of all non-coronial deaths (deaths which are not reportable to a coroner)

  • ensures the appropriate direction of deaths to the coroner

  • provides a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased

  • improve the quality of death certification

  • improve the quality of mortality data.

Medical examiner offices

In England, these are based at acute trusts (and a small number of specialist trusts). They are staffed by medical examiners, supported by medical examiner officers.

The role of these offices is to examine deaths to:

  • agree the proposed cause of death and the overall accuracy of the medical certificate of cause of death (MCCD) with the doctor completing it

  • discuss the cause of death with bereaved people and check if they have questions or concerns about care before death

  • act as a medical advice resource for the local coroner

  • identify cases for further review under local mortality arrangements

  • contribute to other clinical governance processes.

Engaging and involving patients, families and staff after a patient safety incident

The Patient Safety Incident Response Framework (PSIRF) promotes greater engagement with people affected by an incident. It makes sure patients, families and staff are treated with compassion, and are part of any investigation.

Patient safety partner

Simon Wraw is our volunteer patient safety partner.

Patient Safety Partners play a crucial role in enhancing patient safety within the NHS. The main purpose of the role is to be a voice for the patients and community who utilise our services and ensure that patient safety is at the forefront of all that we do. Patient Safety Partners contribute to a safer healthcare environment by bridging the gap between patients, carers, and healthcare providers.

“After retiring and experiencing the loss of both my brother and sister to cancer within a year, I, like many others, felt a strong desire to ‘give something back’. When I was asked if I’d consider a role as a volunteer patient safety partner for NHS Dorset, and then also for the Medicines Quality and Safety group, I jumped at the chance. My only prior experience with the NHS was as a patient. It was quite a transition to get used to the jargon, abbreviations, and the inner workings of the healthcare system.

“I spend one or two days a month on patient safety activities, including chairing the Dorset Patient Safety Strategy Steering Group. This can be daunting as I’m the only lay person among a group of experts (they are very supportive). I take part in meetings where patient safety is a focal point. I review and provide feedback on relevant papers to ensure they are  patient-friendly. I have also helped establish an informal group of volunteer patient safety partners as the role expands across the area.

“A crucial aspect of my role is being an independent voice. I consider the patient’s perspective, and am unafraid to ask questions, no matter how seemingly simple. Drawing from my own lived experiences, I aim to bring some alternative perspective to the discussion.

“Being a volunteer patient safety partner has been an enriching and purposeful journey for me. I am grateful for the opportunity to make a difference and contribute in a small way to the safety and wellbeing of patients.

“It’s been an incredibly rewarding and interesting experience so far; I’ve had the pleasure of meeting and working with a fantastic group of people. I hope that I’ve been able to contribute a valuable patient perspective.”

Responding to patient safety incidents

Valerie’s story

This video is part of a series of patient story videos produced as training resources for the NHS. It demonstrates the impact the initial response to a patient safety incident and subsequent investigation has on the patient.

In this video Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication.

Kathryn’s story

Kathryn recalls her personal experience of temporary paralysis and respiratory arrest after residual anaesthetic drugs were not flushed from her lines and cannula following surgery.

Just culture

The fair treatment of staff supports a culture of fairness, openness and learning in the NHS. It helps staff feel confident to speak up when things go wrong, rather than fear blame. Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented in the future.

Work is being done at NHS Dorset around psychological safety and the Freedom to Speak Up agenda.