Patient Safety Incident Response Framework (PSIRF)

The Patient Safety Incident Response Framework (PSIRF - often pronounced as P-Surf) is how the NHS learns and improves after patient safety incidents happen or are predicted. 

A patient safety incident is when something unintended or unexpected occurs which could have or did lead to harm for 1 or more patients receiving healthcare. 

At our trust, we sometimes call these patient safety events. When they happen, our focus is not on blame, but on understanding what went wrong and how we can improve the systems and processes that support safe care.

Why PSIRF Matters

PSIRF helps us respond to incidents in a balanced and thoughtful way. We ask:

•    What can we learn from this?
•    How can we improve our services to prevent similar incidents in the future?

When there’s an opportunity to learn, we carry out a learning response — this could be a review, or another type of structured approach. If we want to understand the problems that led to the incident occurring in greater detail, we carry out an investigation. We choose the most appropriate method based on the situation.

Learning and Improving Together

PSIRF encourages NHS care providers to share what they learn, both in their organisation and more widely. This helps improve care across the system. It also ensures we have the right resources in place to support both learning and making improvements.

A key part of PSIRF is compassionate engagement. This means involving everyone affected by an incident (patients, families, carers, and staff), in a meaningful and supportive way. We understand that these events can be distressing, and we’re committed to listening, learning, and improving together.

Looking at the Bigger Picture

Patient safety incidents often happen because of complex, overlapping systems, which may lead to individuals making errors. PSIRF helps us look at the wider context and understand how different parts of the system interact and connect to cause or contribute to what happened.

We use system-based approaches to guide our learning. These help us make effective, lasting changes that improve safety for everyone. You can read more about these approaches in our PSIRF policy. 

You can read more about our PSIRF plan here.

Learn more about the PSIRF

Read more about the PSIRF on the NHS England website or watch the video below.