Introduction

Learning from patient safety incidents is a core part of the work of independent providers – and indeed all parts of the health system – in improving the quality of care they provide to millions of patients every year.

In the last few years there has been significant change in the regulatory landscape around this, with the introduction in 2023 of the Patient Safety Incident Response Framework (PSIRF). Replacing the 2015 Serious Incident Framework (2015), PSIRF became mandatory for NHS bodies and providers operating under the NHS Standard Contract, and aims to shift away from investigation-heavy approaches focused on fault or root cause – instead emphasising learning, system-level insight, and understanding the complex conditions shaping care and safety outcomes.

The framework is underpinned by principles of just culture, psychological safety, and partnership with patients and families, and requires organisations to examine how work is carried out in real-world conditions, recognising the influence of human factors, system design, local pressures, and organisational context. This approach demands new capabilities and ways of thinking about safety and improvement.

While one independent healthcare provider was included as part of PSIRF’s “early adopter programme” to support testing and co-design of the scheme, since then IHPN have been working to support our members – who range in size, service type, structure and geography – to ensure the successful implementation of PSIRF throughout the sector. This includes working  with our colleagues including NHS England (NHSE), the Care Quality Commission (CQC), the Deputy Chief Coroner of England & Wales, Healthcare Improvement Scotland (HIS), and Healthcare Inspectorate Wales (HIW); as well as sharing guidance and best practice through a range of initiatives including IHPN’s Share & Learn Community of Practice, and PSIRF Reference Group, and holding bespoke events for Patient Safety Specialists working in the sector.

Three years into implementation, and following interviews with safety and governance leads from across the sector, IHPN are keen to demonstrate the journey independent providers have been on in implementing PSIRF and provide key insights and lessons learned, as well as the challenges that need to be addressed to support further progress in further rolling out PSIRF.

PSIRF – What providers need to do?

The Patient Safety Incident Response Framework (PSIRF) sets out how providers should respond to patient safety incidents to prioritise learning and improvement rather than blame.

Under PSIRF, providers are expected to:

• Maintain a Patient Safety Incident Response Plan (PSIRP)
• Use proportionate learning responses rather than default investigations
• Involve patients and families in learning where appropriate
• Apply systems-based approaches to understand contributory factors
• Ensure learning leads to improvement through governance and quality processes

PSIRF represents a shift towards a culture of openness, system learning, and continuous improvement and helps drive Quality Improvement by ensuring learning from patient safety incidents is systematically translated into practical changes that improve systems, processes, and outcomes for patients, and as a result helps providers target improvement efforts more effectively and reduce the likelihood of similar incidents recurring.