Learning from patient safety incidents

Patient Safety Incident Response Plans

As early adopters of the Patient Safety Incident Response Framework (PSIRF), we are pleased to share our 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 were launched in 2021 as part of a national initiative designed to further improve safety. As part of the project, national guidance was introduced which outlines how providers such as ESNEFT should respond to patient safety incidents, and how and when an investigation should be carried out.

NHS England – Patient Safety Incident Response Framework (Opens in a new window 1.14 Mb pdf

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:

• those which meet the criteria set in the Never Events list
• those which meet Learning from Deaths criteria

NHS England – Never events policy and framework (Opens in a new window)

NHS England – National guidance on learning from deaths (Opens in a new window)

ESNEFT’s Patient Safety Incident Response Plan

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:

• Readmission of patients within 48hrs of discharge where patient requires level 2 or 3 care on admission and where failures were identified regarding the care leading to/immediately following, discharge
• Nutrition & Hydration – incident of significant weight loss or increase in level of care required where the patient is not offered support to eat and drink, food charts have not been documented or monitored and there is documentation that the patient is independently eating and drinking
• Management of Diabetes, patient referred for level 2 or 3 care as a result of failures in monitoring blood glucose levels or incorrect prescription and administration of insulin
• Deterioration of a patient to level 2 or 3 care due to failures in the referral/acceptance of an inpatient between clinical specialties
• Deterioration of a patient to level 2 or 3 care due to the results of a diagnostic test not being acknowledged and acted upon

Our maternity services have also agreed a response in accordance with local and national guidance. There is a Maternity Incident Response Group attended by a group of clinical specialists, where incidents are discussed and the incident review pathway agreed.