Patient Safety Incident Response Framework (PSIRF)

Expert Support for NHS Providers Implementing the National Patient Safety Incident Response Framework

What Is PSIRF?

The Patient Safety Incident Response Framework (PSIRF) is NHS England’s national approach for how healthcare organisations should respond to, learn from, and reduce patient safety incidents. Introduced to replace the 2015 Serious Incident Framework, PSIRF establishes a systems‑based, learning‑focused, and compassionate model for improving safety across the NHS.

PSIRF is now a mandatory requirement for all NHS providers and forms a core part of the NHS Patient Safety Strategy.

Why PSIRF Was Introduced

NHS England developed PSIRF to address long‑standing challenges in the previous Serious Incident Framework, including:

Over‑reliance on root cause analysis
A culture of blame and individual fault‑finding
Inconsistent investigation quality
Limited involvement of patients, families, and staff
Excessive focus on classifying incidents rather than understanding systems

PSIRF shifts the NHS towards evidence‑based safety science, human factors, and proportionate learning responses that genuinely improve care.

What the NHS Aims to Achieve with PSIRF

PSIRF aims to build a mature, learning‑oriented safety culture by:

Embedding systems thinking and human factors principles
Ensuring proportionate and risk‑based responses to incidents
Improving the quality, depth, and consistency of learning
Strengthening patient, family, and staff involvement
Reducing avoidable harm through better organisational learning
Supporting psychological safety and reducing blame

The ultimate goal is a safer, more transparent, and more resilient NHS.

Who Must Comply with PSIRF?

PSIRF compliance is required for:

All NHS provider organisations (acute, mental health, community, ambulance, specialist)
Integrated Care Boards (ICBs) in their oversight and assurance role
Independent sector providers delivering NHS‑funded care
Organisations operating under the NHS Standard Contract, which embeds PSIRF requirements

ICBs must also review and approve provider PSIRF plans annually.

How PSIRF Differs from the 2015 Serious Incident Framework

Key improvements and shifts

From “investigate everything” → to “respond proportionately”
From root cause analysis → to systems‑based learning methods
From blame → to psychological safety and learning
From rigid SI categories → to flexible, risk‑based planning
From variable involvement → to structured, compassionate engagement
From incident counting → to understanding system conditions and work‑as‑done

PSIRF represents a fundamental cultural and methodological shift in how the NHS learns from harm.

Successes and Early Impact of PSIRF

Early evaluation and provider feedback highlight several positive outcomes:

Higher‑quality learning responses with deeper systems insights
Improved staff experience and reduced fear of blame
More meaningful involvement of patients and families
Better prioritisation, reducing unnecessary investigations
Greater use of human factors and safety science
Clearer oversight through ICB assurance
More sustainable workloads for patient safety teams

Many organisations report that PSIRF has strengthened organisational learning and improved the quality of safety actions.

Key PSIRF Documents Every Organisation Must Have

NHS England requires providers to maintain the following:

1. Patient Safety Incident Response Policy (PSIRP Policy)

Defines the organisation’s approach, governance, roles, responsibilities, and alignment with the Patient Safety Incident Response Standards.

2. Patient Safety Incident Response Plan (PSIRP Plan)

Sets out which incidents, themes, or risks the organisation will prioritise for learning responses, based on evidence and local intelligence.

3. Supporting Guidance and Tools

Guidance on engaging patients, families, and staff
Proportionate response selection guidance
Oversight roles and responsibilities specification
Learning response methods (systems‑based approaches, AARs, thematic reviews)
PSIRF preparation and implementation guidance

How Often PSIRF Documents Must Be Reviewed

PSIRP Plan: reviewed annually
PSIRP Policy: reviewed at least every 3 years, or sooner if:
- organisational structures change
- new national guidance is issued
- significant learning indicates revision is needed

ICBs must also review provider plans every year as part of their oversight responsibilities.

Key Methods and Tools Expected Under PSIRF

NHS England expects organisations to use evidence‑based, systems‑focused learning methods, including:

SEIPS (Systems Engineering Initiative for Patient Safety)
Human factors analysis and systems mapping
Work‑as‑done vs work‑as‑imagined analysis
Thematic reviews
After Action Reviews (AARs)
Task analysis and process mapping
Contributory factor frameworks
Resilience and capacity assessments

The emphasis is on understanding system conditions, not identifying individual fault.

What Qualifications Are Needed to Provide PSIRF Training?

NHS England does not mandate a formal accreditation, but training providers must demonstrate:

Expertise in:

Human factors and ergonomics
Systems thinking and safety science
Patient safety investigation practice
Psychological safety and compassionate engagement
NHS governance and regulatory frameworks

Experience in:

Delivering systems‑based learning responses
Working within NHS patient safety or governance roles
Supporting patient and family involvement
Facilitating simulations and case‑based learning

Capability to:

Teach practical investigation skills
Deliver training aligned with PSIRF Standards
Support organisations through implementation and oversight

Promethean Human Designs meets these expectations through Chartered Human Factors expertise, NHS governance leadership, and extensive experience delivering PSIRF‑aligned training.

Please click here to access our training offerings, or click here to learn more about what PSIRF Training entails.

How Often Should Staff Repeat PSIRF Training?

While NHS England does not specify a fixed interval, best practice across the NHS is:

Full PSIRF training every 2–3 years
Annual refreshers for investigators, oversight roles, and patient safety specialists
Additional training when:
- roles change
- new methods are introduced
- national guidance is updated

ICBs may set local expectations for providers.

Why Work With Promethean Human Designs?

Promethean Human Designs provides evidence‑based, human‑factors‑led PSIRF training and consultancy designed specifically for NHS organisations. We support providers and ICBs to:

Implement PSIRF effectively
Strengthen governance and oversight
Build internal investigation capability
Deliver high‑quality systems‑based learning responses
Improve patient, family, and staff experience

Our approach is grounded in Chartered Human Factors expertise, NHS governance leadership, and real‑world investigation experience.