OCTOBER 20248During my career, I have seen the investigation, management and implementation of corrective actions for countless patient safety incidents. Recently, I have been reflecting on the top words that come to mind when I think of these cases: distress, questions, blame, retribution, and costs. Words like safety, improvement, learning and closure feature much less frequently. Why? Historically, clinical governance and medicolegal processes in large health service organisations have placed a heavy emphasis on being defensive. An apology, even as an expression of regret for an unintended outcome, may have been viewed as a risk to the system, the organisation and the individual. But medicine is rarely black or white; most of our practice happens in those grey areas, where decisions are made by balancing medical knowledge, clinician experience, the information available at the time, and patient preferences.There is no surgery or tablet with zero complications or side effects. It should be no surprise that things sometimes do not go as planned. When unintended outcomes happen, openness, honesty, transparency and learning are needed. These are the ingredients for a safer, more effective, more caring, more responsive and better-led healthcare organisation. One which delivers better patient satisfaction, receives fewer complaints and spends less on litigation. A complete change of mindset is needed. The National Health Service in England has recognised for some time that top-heavy investigations can sometimes focus too much on liability and do not enough onunderstanding how and why incidents happen or contributory factors. This can lead to a failure to prevent recurrence.The Patient Safety Incident Response Framework (PSIRF) marks a significant shift in howpatient safety incidents are dealt with. In this article, we explore the key considerations for adopting PSIRF within an organisation and its impact. PSIRF is a transformative approach adopted by NHS England to enhance patient safety through effective response to patient safety incidents. It signifies a paradigm shift from the previous Serious Incident Framework established in 2015, aiming to foster a culture oflearning and improvement rather than blame and punishment.At the heart of PSIRF is the commitment to understanding how incidents occur, including the contributory factors, rather than merely documenting them. This framework encourages a system-based approach to incident response, ensuring that lessons are learned and that similar incidents are prevented in the future.PSIRF integrates four key aims to revolutionise patient safety incident response:A NEW WAY OF LOOKING AT PATIENT SAFETY AND QUALITY IMPROVEMENTIn My OpinionBy Kolitha Basnayake, Deputy Medical Director, University Hospitals Birmingham NHS Foundation TrustA CRUCIAL ASPECT OF PSIRF IS THE ENGAGEMENT AND INVOLVEMENT OF THOSE AFFECTED BY PATIENT SAFETY INCIDENTS
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