At NHS Dorset, the Patient Safety and Risk team works to improve patient and service safety and minimise risk.
The team:
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:
This document was published alongside the PSIRF. It says anyone affected by an incident (for example patients, families, and staff):
Resources
Find out more about the Patient Safety Incident Response Framework (PSIRF), 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.
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:
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:
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 partners
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.