Patient Safety Incident – Investigation and Response (PSIRF)

Course Outline:

This course equips delegates to design and deliver proportionate, systems‑based learning responses to patient safety incidents in line with the NHS Patient Safety Incident Response Framework (PSIRF). Participants will learn how to use organisational Patient Safety Incident Response Plans (PSIRPs) to determine the most appropriate response to an incident, recognising that PSIRF removes harm‑threshold triggers and instead promotes data‑driven, context‑specific decision‑making.

Delegates will explore PSIRF‑endorsed learning response methods, including patient safety incident investigations (PSIIs), After Action Reviews, multidisciplinary team (MDT) reviews, and swarm huddles, using the SEIPS systems‑based framework as the foundation for analysis. These approaches replace traditional linear root cause analysis as the default investigative method.

Participants will develop skills in information gathering, including questioning techniques, observations, and other human‑factors‑based tools. These methods help build a clearer understanding of system conditions and interactions that contributed to the incident. 

The course also covers how to respond in line with the patient safety incident response standards.

Key Learning Outcomes:

By the end of the course, delegates will be able to:

• Apply SEIPS‑based methods to understand system interactions and contributory factors, replacing traditional root cause analysis approaches.
• Gather high‑quality information using interviews, observations, link analysis, and walkthroughs to understand “work as done” and inform system‑level learning.
• Engage patients, families, and staff with compassion and transparency, in line with PSIRF guidance and national standards for involvement. 
• Select and resource learning responses in accordance with the patient safety incident response standards, focusing on competencies, capability, and supportive oversight.
• Synthesise information and develop credible, measurable safety actions using national tools such as the Safety Action Development Guide.
• Produce clear, well‑structured PSIRF‑aligned outputs that prioritise learning and improvement, rather than assurance reporting.
• Identify when nationally mandated responses (e.g., Learning from Deaths, Never Events) apply and when a PSII is specifically required.
• Share learning effectively, recognise barriers to improvement, and embed findings into wider organisational safety work.