System Safety | Our projects

PSIRF is a major step towards improving safety management across the healthcare system in England and greatly supports the NHS to embed the key principles of a patient safety culture. It ensures the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals, allowing for more effective learning and improvement, and ultimately making NHS care safer for all.

Patient safety collaboratives (PCS) supported the national adoption and scale up of PSIRF with fidelity to the core principles, working in collaboration with partners in NHS England's regional teams. All NHS provider trusts have now transitioned to PSIRF, and the PSCs continue to support embedding PSIRF and learning from incidents to inform and develop improvement work.

PSIRF in primary care:

PSIRF has not, as yet, been mandated in primary care but it is included in the primary care patient safety strategy. PSIRF is currently being piloted in primary care by a number of GP practices, GP federations, primary care networks and ICBs.

Wessex cross system Patient Safety Incident Investigation (PSII) thematic review:

Health Innovation Wessex carried out a cross-system thematic review of Wessex systems (Dorset, and Hampshire and Isle of Wight) to explore common and recurring factors contributing to patient safety incidents to help inform improvement priorities within the systems.

A total of 27 anonymised reports from ten organisations were included in the review which led to three overarching themes identified: ‘Communication that connects’, ‘Robust systems, safe care’ and ‘From roles to goals’. The full thematic review can be read on our website.

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