PSIRF Implementation: Benefits and Guidance for Healthcare Providers


While it may seem like just another acronym in the healthcare landscape, PSIRF represents a significant shift towards a system-based approach to patient safety, offering tangible benefits for both patients and healthcare providers.

From minimising risks and improving learning to fostering trust and transparency, PSIRF implementation can be a transformative journey. Whether you’re just starting out or already navigating the process, this guide will equip you with the knowledge and resources to unlock the full potential of PSIRF in your organisation.

So, in this article we explore the compelling benefits, and provide practical guidance to ensure success with your PSIRF implementation.

What is PSIRF?

PSIRF stands for the Patient Safety Incident Response Framework. It’s a framework developed by the National Health Service (NHS) in England to help healthcare organisations respond to patient safety incidents effectively.

PSIRF replaces the Serious Incident Framework (SIF) and its implementation is a mandatory requirement for all NHS organisations that provide services under the NHS Standard Contract. This includes secondary care providers like private hospitals and clinics that treat NHS patients although primary care providers, which include most GPs, dentists, and opticians, are not currently required to implement PSIRF.

“Primary care providers may also wish to adopt PSIRF but it is not a requirement at this stage”


While mandatory for NHS-contracted services, it is optional for most private healthcare providers. However, the framework’s focus on patient safety might incentivise wider adoption in the future.

So, primary care providers and private healthcare organisations may benefit from understanding PSIRF and how it is implemented as a quality improvement process, and to improve patient safety.

Why is PSIRF being implemented?

At Verita, our experience of carrying out independent healthcare investigations provided us with insight that there was too much focus in the investigation itself, resulting in a missed opportunity to learn from serious incidentsAs well as this, the lack of expertise in human factors means workable solutions to underlying causes were not properly developed or addressed. 

Following a review of NHS trust investigation reports, the CQC supported our view by recommending a proportional approach to serious incident investigations, which also promotes learning from incidents.

The patient safety incident response framework represents a fundamental shift in how patient safety incidents are approached and investigated. PSIRF provides a tiered approach to incident response and encourages organisations to use system-based learning methods to investigate incidents, such as human factors analysis.

Moreover, central to PSIRF is compassionate engagement with those affected by patient safety incidents which stems from the understanding that meaningful learning and improvement can only happen if those directly impacted are heard and involved.

Not only that, PSIRF is about establishing good culture and practices in healthcare organisations to provide a foundation for Just Culture to be workable.


What is the current status of PSIRF implementation?

Initial implementation of PSIRF began in September 2022 with the transition period expected to take approximately twelve months, meaning completion should have been achieved by Autumn 2023. However, organisations are expected to continuously improve their PSIRF practices and strive towards its core principles of promoting a culture of learning and improvement in patient safety making implementation an ongoing journey rather than a fixed endpoint.

The NHS are hosting a series of PSIRF webinars up to September 2024 to support organisations, acknowledging that the PSIRF framework is still in the process of being operationalised.

Does PSIRF replace SIF and RCA investigations?

PSIRF replaces the Serious Incident Framework (SIF) in the NHS, although RCA investigations can still be used within the new framework. In contrast with SIF, there is no distinction between ‘patient safety incidents’ and ‘serious incidents’. SIF focused on specific incident types and thresholds for investigation, while PSIRF applies to all incidents with potential for harm or learning.

RCA is no longer the sole investigative method, but can be used as part of a patient safety incident investigation (PSII) to identify the root cause of an issue. PSIRF recognises the limitations of the linear approach of RCA investigations by encouraging a more systemic and qualitative analysis which focuses on understanding the incident’s contributing factors and learning opportunities.

How is PSIRF implemented?

Implementing PSIRF is a complex process with a wide range of requirements which may initially feel overwhelming for those involved in busy healthcare organisations. It requires a cultural shift within organisations and careful planning to ensure effective implementation.

First is the preparation phase which involves orientation and familiarisation with the PSIRF framework, its principles, and requirements. Following that, organisations need to assess their existing systems and processes for responding to patient safety incidents, identifying strengths and weaknesses.

It is then important for organisations to define governance structures, along with roles and responsibilities for implementing PSIRF, such as a PSIRF lead and investigator/s. Responsibilities extend to staff at all levels so everyone should receive training and education on PSIRF principles and their role within the framework.

As well as this, a PSIRF response plan needs to be developed outlining how the organisation will respond to different types of incidents, including reporting procedures, investigation methods, communication strategies, and learning activities.

It is also vital that healthcare organisations develop and implement sufficient tools and resources needed for reporting, investigating, and analysing incident data.


Implementing PSIRF for responding to incidents

PSIRF can then be implemented and start being used for responding to incidents. Apply the framework to all incidents with potential for harm or learning, not just those meeting specific criteria like the previous SIF framework.

  • Conduct investigations using appropriate methods like multidisciplinary team reviews, debriefs, or system-focused analyses depending on the incident type and learning objectives.
  • Focus on learning and improvement by analysing incident data to identify common themes and systemic issues, and implement changes to prevent similar incidents in the future.
  • Engage with affected individuals and families with open and compassionate communication with those involved in incidents.
  • Monitor and evaluate PSIRF effectiveness by regularly reviewing and evaluating the implementation, so that areas for improvement can be identified, and adjustments made as needed.

PSIRF roles and responsibilities

Implementing PSIRF effectively requires clearly defined roles and responsibilities within an organisation, although specific roles and responsibilities may vary depending on the size and structure.

  • Executive Lead: Oversees the development, implementation, and review of the PSIRF policy and plan, ensuring compliance with PSIRF standards and best practices. They are responsible for promoting a culture of learning and improvement in patient safety and providing resources and support for PSIRF implementation.
  • PSIRF Lead: Manages the day-to-day operations of the PSIRF system and is responsible for coordinating the investigation of patient safety incidents. This role includes developing and maintaining PSIRF policies, procedures, and tools, as well as monitoring and evaluating the effectiveness of PSIRF implementation.
  • Incident Reporting Officer(s): Here, the responsibility is to receive and process reports of patient safety incidents and determine if an incident meets criteria for investigation. This is an important role because it includes providing the initial response and support to those affected by the incident.
  • Investigator(s): Conducts investigations of patient safety incidents in accordance with PSIRF principles. By identifying the contributing factors and potential for learning, they can then make recommendations for improvement.
  • Learning and Improvement Lead: Analysing incident data to identify trends and patterns is a fundamental part of PSIRF in order to develop and implement action plans to address systemic issues. It is the responsibility of the Learning and Improvement Lead to develop and share these learnings with staff and stakeholders.
  • Communication Lead: Develops and implements communication strategies for managing incidents and sharing learning. Responsibilities include ensuring open and compassionate communication with those affected by incidents as well as providing regular updates on PSIRF activities and outcomes.
  • Staff at all levels: In order for PSIRF to be implemented correctly all staff are responsible for reporting patient safety incidents in a timely manner. Staff should also cooperate with investigations and learning activities and implement changes to improve patient safety.
  • Additional roles: An Oversight Group can provide independent oversight of the PSIRF system and provide recommendations for improvement. There is also the possibility of a Second Victim Support role whose responsibility involves providing support to staff who are involved in patient safety incidents.

Serious Incident Investigations

How Verita can help

Our extensive work as a healthcare management consultant with the NHS provides us with a wealth of experience when it comes to helping organisations implement changes to incident investigation frameworks. 

If you need help carrying out investigations our serious incident investigation reporting service draws on experience from over 200 serious incident investigations to develop solutions that give the information needed to target problem areas, quality assure investigations and investigative processes, prevent backlogs and increase organisation-wide learning.

Feeding into this is our healthcare app, Eva, which transforms the way serious incident investigations are conducted in public and private hospitals across the UK. Eva makes investigations less of an ordeal for frontline staff to complete, patients to engage with, and IT staff to implement. 

Eva is easy to use, cost effective, integrates with existing IT systems and standardises the investigation process. It also offers the benefit of anonymised data aggregation and thematic analysis across multiple locations, making it possible to gain informed insights and identify trends, ultimately reducing the number of serious incidents that occur.

This also equips us to manage serious incident investigation backlogs which can help organisations implement PSIRF by taking pressure of existing workloads. By sending us the underlying paperwork electronically, we use our technology to investigate the incident. Eva enables us to provide investigations which get to the heart of the problem, using the analytical tools recommended by the National Patient Safety Agency and NHS Improvement. 

serious-incident investigation-team

We also provide a patient safety incident investigation training course led by an experienced investigator to help those who carry out investigations, or reviews such as nurses, doctors, managers and associated healthcare workers. Participants learn how systematic investigation can be used to discover how and why an incident occurred and identify solutions to prevent similar incidents happening again. It covers every step of the investigative process which is a crucial element of PSIRF implementation.

In summary

PSIRF is a significant step forward in how the NHS responds to patient safety incidents. By focusing on understanding how incidents happen, learning from them, and responding proportionately, PSIRF has the potential to make a real difference to patient safety.

It also creates a better environment for everyone involved by encouraging a just culture and advocating a co-ordinated and data-driven approach to patient safety incident response that prioritises compassionate engagement with those affected.

But, in order for PSIRF to be implemented correctly staff at all levels need to adjust the way they respond to incidents and many new roles and responsibilities need to be adopted. This is certainly not an easy task but Verita can help in many of these areas to make PSIRF implementation more successful in your organisation.

If you would like to know more about PSIRF implementation and how we can assist your teams during its transition, please book a free consultation or contact Ed Marsden on 020 7494 5670 or [email protected].


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