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Patient Safety Incident Response Plan

Patient Safety Incident Response Plan (PSIRP)
Yorkshire Health Solutions

1. Introduction

Yorkshire Health Solutions (YHS) is committed to delivering safe, high-quality care and services. This Patient Safety Incident Response Plan (PSIRP) outlines our structured approach to responding to patient safety incidents. It aligns with the NHS Patient Safety Incident Response Framework (PSIRF), promoting continuous learning, improvement, and fostering a just culture.

2. Purpose

This plan ensures that YHS responds to patient safety incidents in a timely, compassionate, and system-focused manner. It establishes how YHS identifies, assesses, and learns from incidents to enhance patient safety and care delivery, while ensuring compliance with national requirements such as Duty of Candour and CQC reporting obligations.

3. 3. Scope

This plan applies to all employees, contractors, and affiliated professionals working within YHS, across all service settings. It also covers collaborative responses with Integrated Care Board (ICB) partners, regulators, and other external agencies.

4. Objectives

In line with PSIRF, our objectives are to:

  • Compassionately engage and involve patients, families, and staff affected by patient safety incidents.
  • Apply system-based approaches to understand the underlying causes of incidents.
  • Deliver considered and proportionate responses tailored to incident severity and complexity.
  • Enable supportive oversight focused on strengthening incident response systems.
  • Use data and learning from incidents to drive continuous improvement across services.

5. Key Principles

  • Just and Learning Culture: Promote openness and transparency, encouraging reporting without fear of blame.
  • Engagement: Ensure compassionate communication with those affected, led by the Patient Safety Engagement Lead – Grace Stephenson, who will coordinate involvement processes and provide a consistent point of contact.
  • Systems Thinking: Use root cause analysis and systems-based tools (e.g., SEIPS, London Protocol) to understand contributory factors.
  • Proportionality: Match the response approach to the impact and risk associated with the incident. Criteria include:

             – Low impact / no harm: case review or local learning response
             – Moderate impact / limited harm: thematic review or structured learning response
             – Serious harm, death, or Never Event: independent investigation

  • Continuous Improvement: Embed learning into practice through education, policy updates, and system redesign.

6. Incident & Improvement Profiles

  • Incident Types: Common incidents include medication errors, delays in care, documentation issues, and falls. Emerging risks include digital record transition challenges and staffing pressures.
  • Improvement Priorities: YHS will prioritise safe medicines management, effective communication during care transitions, and strengthening safety culture across services.
  • Legacy Serious Incidents (SIs): YHS is committed to closing all legacy SI investigations under the previous framework in line with national guidance, while new incidents will be managed under PSIRF.

7. Use of Data

  • Data from the Learning from Patient Safety Events (LFPSE) system will be analysed quarterly.
  • Patterns such as repeat incident categories, contributory factors, and high-risk service areas will be identified.
  • Findings will be reviewed by the Patient Safety and Quality Group (PSQG) and shared with frontline teams through safety huddles, newsletters, and intranet updates.

8. Contact Us

8.1 Identification and Reporting

  • All staff must report suspected or actual patient safety incidents via the internal incident reporting system within 24 hours.
  • Immediate safety actions must be taken where required to protect patients and staff.

8.2 Initial Assessment and Triage

  • The Patient Safety Team (PST) will review incidents within 72 hours to determine:

           – Impact and potential for harm
           – Need for immediate intervention
           – Appropriate level of investigation or response

8.3 Patient and Family Involvement

  • Patients and families will be informed of the incident within 10 working days.
  • The Patient Safety Engagement Lead will coordinate ongoing communication and involvement opportunities.

8.4 Response Options

  • Case Review
  • Thematic Review
  • Structured Learning Response
  • Independent Investigation (Serious Incidents)

8.5 Review and Learning

  • Outcomes and recommendations will be documented and shared across relevant teams.
  • Themes and trends will be reviewed quarterly by the PSQG and annually by the Board.

9. Governance and Oversight

  • The Patient Safety and Quality Group (PSQG) oversees implementation and effectiveness of this PSIRP.
  • The Board Safety Champion holds executive accountability for patient safety.
  • Updates will be shared with the Integrated Care Board (ICB) quarterly and as required for serious incidents, ensuring collaboration and oversight.
  • External obligations (CQC, coroner, NHS England) will be met in line with statutory reporting requirements.

10. Training and Support

  • All staff will complete Level 1 training on patient safety incident reporting and learning.
  • Key staff, including managers and investigators, will complete Level 2 training on systems-based investigation.
  • The Learning Response Lead is Grace Stephenson, who will oversee training delivery and ensure the quality of investigations.
  • Staff involved in incidents will be offered emotional support and signposting to health and wellbeing services.

11. Monitoring and Review

  • KPIs will be monitored and reported quarterly, including:

            – % of incidents reported within 24 hours
            – % of reviews completed within agreed timeframe
            – % of action plans implemented within 6 months
            – Patient/family satisfaction with involvement

  • An Annual Learning Report will be published and presented to the Board.
  • This policy will be reviewed annually or sooner if required due to national policy changes or significant incidents.

12. Publication

  • This PSIRP will be published on the YHS website to ensure transparency with patients, families, and the public.

13. References

  • NHS Patient Safety Incident Response Framework (PSIRF)
  • NHS England’s guidance on systems-based investigation
  • Duty of Candour legislation
  • Learning from Patient Safety Events (LFPSE)
  • CQC “Learning from safety incidents” guidance
  • Healthcare Safety Investigation Branch (HSIB) principlesThis PSIRP will be published on the YHS website to ensure transparency with patients, families, and the public.