Learning from patient safety incidents


We are among the first trust’s in England to introduce a new Patient Safety Incident Response Plan (PSIRP) which sets out how we will learn from patient safety incidents. This will help us to continually improve the quality and safety of the care we provide, as well as the experience which patients, families and carers have when using our services.

Patient Safety Incident Response Plans are being launched as part of a national initiative designed to further improve safety, which ESNEFT is helping to test before it is rolled out across the rest of the NHS in autumn 2021. As part of the project, national guidance – called the ‘Patient Safety Incident Response Framework’ – is being introduced which outlines how providers such as ESNEFT should respond to patient safety incidents, and how and when an investigation should be carried out.

The national framework defines a number of national priorities which we must investigate locally through an in-depth investigation, called a patient safety incident investigation. This focuses on addressing causal factors and uses improvement science to prevent or continuously and measurably reduce repeat patient safety risks and incidents. Examples of these are:

In addition, ESNEFT has developed a local plan by looking at our past safety data, reviewing our organisational risks and Trust priorities and through discussion with colleagues, patients and their carers. Through this review, we have identified the following things we must investigate:

  • Incidents at night or during weekends where the assessment of an inpatient was delayed because ward staff did not carry out effective monitoring to recognise deterioration, or take action to escalate the issue.
  • Maternity incidents specific to mothers where a near miss took place because bleeding was not recognised or managed in a timely way. These incidents are not covered by Each Baby Counts
  • Medication incidents which happen when blood glucose is not monitored effectively in inpatients.
  • Medication incidents which happen when the patient has been prescribed more than one anticoagulation medication.
  • Delayed decision making when an inpatient is being managed between two or more clinical specialties which results in an admission or transfer to a higher level bed, such as critical care.
  • Nutrition and hydration incidents which take place because of a delay in recognising and managing patients who are at risk of weight loss or other complications as a result of the accuracy of a malnutrition universal screening tool (MUST) risk assessment.

Throughout any investigation, we will provide each patient, family member or carer with a named contact who will help them access support services and listen to their questions or concerns before making sure they are answered openly and honestly.

All investigations will begin as soon as possible after the incident has taken place, and will usually take between one and three months to complete. Learning will then be shared with the relevant teams so that action can be taken to prevent a similar incident from happening again in the future.


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