PSIRF Explained: What It Means for Incident Learning

PSIRF, the Patient Safety Incident Response Framework, is NHS England's approach to responding to patient safety incidents so that services learn and improve. Published in August 2022, it replaced the Serious Incident Framework (2015). It moves away from investigating a small number of "serious incidents" to find a single root cause, towards proportionate, system-based learning responses.

This guide explains what PSIRF asks of providers, the learning response methods it uses, where root cause analysis tools such as the 5 whys still fit, and what it means if you run an independent or social care service. PSIRF applies to NHS-funded care in England.

Why PSIRF replaced the Serious Incident Framework

Under the old framework, the "serious incident" label and its threshold decided which incidents were investigated, and how. NHS England describes PSIRF as much broader in scope, because it no longer focuses on the small proportion of incidents deemed "serious". Everyday incidents and near misses can teach as much as the rare dramatic ones.

PSIRF removes the "serious incident" classification and its threshold. Instead, each provider decides how to respond to incidents based on what it can learn, and plans its approach in advance. NHS England said organisations should complete the move to PSIRF by autumn 2023.

The framework is clear about what learning responses are not for. They exclude activities that apportion blame, determine culpability or preventability, or identify cause of death. Those questions still matter, but they belong to other processes, such as HR, professional regulation, the police and coroners' inquests.

The four aims of PSIRF

The NHS England PSIRF page sets out four aims:

1. Compassionate engagement and involvement of those affected by patient safety incidents: patients, families and staff.
2. A range of system-based approaches to learning from patient safety incidents.
3. Considered and proportionate responses to patient safety incidents.
4. Supportive oversight focused on strengthening how the response system works and improves.

In practice, providers write a patient safety incident response policy and a plan that sets out which incident types they will look at in depth, which they will respond to more lightly, and which they will review as a theme rather than one by one.

Learning response methods

NHS England's patient safety learning response toolkit gives providers a set of tools. The main learning responses are:

• Patient safety incident investigation (PSII): an in-depth review of a single incident or a cluster, used where an incident indicates significant patient safety risk and potential for new learning. Some incidents require a PSII under national rules, such as deaths that meet the Learning from Deaths criteria for investigation.
• After action review (AAR): a structured discussion around four questions: what was expected to happen, what actually happened, what was the difference, and what can be learned.
• Swarm huddle: staff gather soon after an incident, ideally where it happened, to talk through what happened and agree how to reduce the risk.
• Multidisciplinary team (MDT) review: used to find learning across several similar incidents, agree contributory factors and system gaps, and understand how work is really done.
• Thematic review: looks at patterns across a group of incidents or other information, rather than one event.

The toolkit also includes guidance on interviews, observation, walkthroughs, timeline mapping and writing safety actions, plus the SHARE debrief tool for talking to staff about the outcome.

Systems thinking and SEIPS

At the heart of PSIRF is a shift from asking "who made the mistake?" to "what about the system made this outcome likely?". The toolkit uses SEIPS, the Systems Engineering Initiative for Patient Safety, a framework developed by Pascale Carayon and colleagues at the University of Wisconsin. NHS England describes it as a framework for understanding outcomes within complex socio-technical systems.

SEIPS asks you to look at the whole work system around an incident, for example:

• the people: their experience, workload, fatigue and wellbeing
• the tasks: how complex they are, and how often they're interrupted
• tools and technology: equipment, IT systems, forms and charts
• the organisation: staffing, rotas, culture, communication and handovers
• the environment: layout, noise, lighting and space, plus outside pressures

Take a missed medication dose on a night shift. A person-focused review stops at "the nurse forgot". A systems review asks why: two staff off sick, a pharmacy delivery that arrived late, an electronic record that didn't flag the dose, and a medicines round interrupted by a fall. The actions that come out are very different.

Where root cause analysis and the 5 whys still fit

PSIRF doesn't mention root cause analysis, and NHS England's toolkit is built around SEIPS rather than the 5 whys or fishbone diagram. The framework favours approaches that avoid a simplistic, linear search for a single cause. That's the main criticism of the 5 whys: asking "why?" five times tends to lead down one track to one answer, when most incidents have several contributing factors working together.

That doesn't make the tools useless. The skills behind good root cause analysis carry across directly:

• gathering the facts before forming a view
• building an accurate timeline
• interviewing staff in a supportive, non-blaming way
• looking for contributing factors across the whole system
• writing specific actions that change the system, not just "remind staff"

A fishbone diagram, used to map contributing factors under several headings, can sit comfortably alongside a systems approach. The 5 whys can still help a team dig into one factor, as long as nobody treats the first answer as the whole story.

Does PSIRF apply to independent and care providers?

NHS England says PSIRF is mandatory for services provided under the NHS Standard Contract. Its guidance on applying PSIRF outside NHS trusts confirms this includes independent providers delivering NHS-funded care, and that smaller providers can apply it proportionately, for example by sharing resources with larger organisations.

Social care providers that aren't commissioned through the NHS Standard Contract aren't contractually required to adopt PSIRF, though NHS England notes some are keen to align with its principles. If you run a care home or supported living service, check your contracts and ask your commissioners what they expect.

Either way, CQC-registered providers in England still have to assess, monitor and improve the safety of their services under Regulation 17 (good governance), and NHS England confirms PSIRF doesn't change any of the requirements of the duty of candour. Good incident reviews also depend on good records, which is where defensible documentation helps, and on handling concerns from families well, covered in complaints handling for managers.

How Kasorb can help

Our root cause analysis training teaches staff to investigate incidents properly: gathering the facts, building a timeline, and finding contributing factors rather than blaming individuals. It covers systems and human factors, a just culture, interviewing staff, tools including fishbone diagrams, five whys and contributory factor frameworks, involving the people affected and the duty of candour, and writing SMART actions. Choose a foundation course, a workshop or a two-day course, on site anywhere in the UK or live online, using case studies, including an anonymised incident of your own if you like. Your trainer has used these skills for real. It's one price for the group, and certificates are emailed the next day.

This guide summarises the law and guidance; it isn't legal advice.

FAQs

What does PSIRF stand for?

PSIRF stands for the Patient Safety Incident Response Framework. It's NHS England's framework for how providers of NHS-funded care in England respond to patient safety incidents, with a focus on learning and improvement rather than blame. It replaced the Serious Incident Framework.

When did PSIRF replace the Serious Incident Framework?

NHS England published PSIRF in August 2022 and expected organisations to complete the move from the Serious Incident Framework (2015) by autumn 2023. It's a contractual requirement for services provided under the NHS Standard Contract.

Is root cause analysis still used under PSIRF?

PSIRF doesn't use the term root cause analysis and favours system-based approaches over looking for a single cause. The underlying skills, such as building timelines, interviewing staff and finding contributing factors, are still central to learning responses like a PSII or after action review.

What are the PSIRF learning responses?

The main learning responses in NHS England's toolkit are the patient safety incident investigation (PSII), after action review, swarm huddle, multidisciplinary team review and thematic review. Providers choose which to use in their patient safety incident response plan, based on what they can learn.

Does PSIRF apply to care homes?

Only where care is provided under the NHS Standard Contract. Other social care providers aren't contractually required to adopt it, though some align with its principles. CQC-registered providers in England must still monitor and improve safety and meet the duty of candour.