The Patient Safety Incident Response Framework (PSIRF) is an NHS approach designed to improve the response to patient safety incidents, including those in maternity care. Here’s a concise outline tailored to maternity care incidents:
Key Components of PSIRF in Maternity Care
- Focus on Systemic Improvement
- Shift from Blame to Learning: PSIRF emphasises understanding system failures rather than focusing on individual blame. It encourages learning from incidents to make meaningful safety improvements.
- Cultural Shift: PSIRF promotes a culture that prioritises learning from mistakes and improving systems rather than punishing individuals. This approach is especially crucial in the high-stakes environment of maternity care, where incidents can have serious and long-lasting impacts.
- Learning Organisation: Maternity units are encouraged to become “learning organisations,” continually analysing processes and outcomes to identify ways to enhance care for mothers and babies.
- Incident Prioritisation
- Risk-Based Decision Making: Instead of investigating every incident in the same way, maternity care teams use a risk assessment model to determine which events warrant a comprehensive investigation or thematic review. This ensures that resources are focused on cases where the most valuable lessons can be learned.
- Types of Incidents: High-priority events in maternity might include maternal death, stillbirths, severe maternal morbidity, or unexpected neonatal complications such as cooled babies at term.
- Comprehensive Investigation Process: After an initial review of the clinical records and discussions with staff it is then decided on the level of proportionate response:
- Local review and learning
- After Action Review
- PSII review
- Thematic Review
- Review of the safety event: Using the SEIPS (System Engineering Initiative for Patient Safety) framework to underpin the safety event review process which considers;
The Work System – Tools/Technology, Organisational Factors, Tasks, Person (s) Internal Environment, External Environment.
The Process – The journey of the safety event/patient and their journey in interactions within the healthcare system
The Outcome – This refers to the consequence of the work system and the process
As part of a review of a safety event it is important that there is also;
Patient/Family Involvement – As part of any review of patient safety review it is vital that their questions are explored and answered and regular contact is maintained.
Staff and witness accounts – Investigative interviewing principles are used speak to those involved without assigning blame.
Staff support – Ensure that healthcare professionals involved in the incident receive emotional and psychological support, recognising the emotional toll that incidents can have on those who provide care.
Data collection – Clinical records and guidelines
- Response
Targeted Interventions:
- Formulate clear, SMART action plans with the wider multidisciplinary team to mitigate against recurrence. For example;
- Revising guidelines
- Audit.
- Changes in clinical practice Implementing new communication tools like handover checklists.
- Providing more training opportunities.
- Use the Just Culture guide to support staff
- Continuous Learning and Monitoring
- Safety Improvement Cycles: The effectiveness of action plans is monitored through regular audits, feedback and via the reporting of similar incidents. This can provide assurance that the SMART actions and associated changes are having the desired impact. It also provides the opportunity for new areas of improvement to be identified and measures to address them put in place.
- Feedback Loops: Share findings and updates with maternity staff and patients to foster an open, learning culture.
- Communication of Findings: Share learning points widely across the maternity team and the wider healthcare organisation. This might include briefings, training sessions, or updates to clinical guidelines.
PSIRF Goals in Maternity Care
- Enhance Patient Safety: By addressing systemic issues proactively, PSIRF seeks to reduce preventable harm and improve outcomes in maternity care.
- Promote Transparency and Trust: Engaging families and being transparent about incident investigations and outcomes fosters trust between healthcare providers and the community.
- Support Staff Wellbeing: Recognising the emotional impact of adverse events on maternity care providers, PSIRF emphasises the importance of a supportive, non-punitive environment.
Overall, PSIRF is designed to ensure that maternity services not only learn from serious incidents but also embed this learning into everyday practice to create safer care environments.