Patient Safety Incident Response Framework (PSIRF)

Elysium’s PSIRF Plan and Policy are available to be downloaded.


Patient safety is at the heart of everything we do at Elysium and it’s everyone’s responsibility.

We spoke with Jo Scott, Group Director, Quality Assurance at Elysium about PSIRF, an upcoming change to the system we use to respond to patient safety incidents. She tells us more:

safety sign

“Currently, when responding to incidents involving people supported in hospital or social care settings, health and social care organisations, including Elysium, use the Serious Incident Framework (SIF). This is a system which has thresholds in place which determine whether an incident will be investigated further, and these are based on levels of harm, or potential levels of harm. It also sets out strict timetables. However, in settings such as ours, they may not always be the most effective or efficient way of responding to incidents.

“This Autumn, across health services nationally, the SIF is being replaced by a system called PSIRF (Patient Safety Incident Response Framework). This system focuses more on flexibility, improvement and learning. Elysium is currently preparing to roll it out across our services.

“With PSIRF, there’s much less focus on ‘what went wrong or who did it wrong’. It promotes looking at the whole ‘system’ around an incident, moves away from talking about ‘serious incident investigations’ or ‘root cause analysis’. It will involve the people we support and colleagues and really focus on improvement and engagement.

Working Together“The aim is to move away from repeatedly carrying out incident investigation reports for every single case as in some cases, they’re simply not effective or efficient. But that doesn’t mean incidents or concerns won’t be carefully considered and properly investigated, far from it. Safeguarding, CQC referrals, health and safety and duty of candour reports, for example, all remain unchanged.

“The introduction of PSIRF is about creating less of a ‘tick-box’ or ‘blame’ scenario and looking beyond to the system and responding proportionately to incidents. There’s increased flexibility on how an incident can be responded to, with an investigation being just one learning response option, a change which will likely take the most getting used to and ensuring that people, their families and clinical staff are directly involved in the learning is key.

“Annually, across Elysium, we have 69,000 recorded ‘incidents’. All of these are logged using the IRIS system that we currently and will continue to use. Around 350 of those incidents reach the SIF harm threshold which is serious enough that it leads to a more in-depth review called a ‘root cause analysis’. Going forward, that won’t be the case under PSIRF. There won’t be ‘serious’ incidents and ‘other’ incidents. Harm will no longer be the main reason to review or closely look at an incident. PSIRF will help us look more at what can be clinically learned to prevent harm occurring.

“The SIF system is also geared to look for failings and blame rather than to look at learning and support. When a patient safety incident occurs, it will be unintended and unexpected, rarely is it malicious. We firmly believe no-one comes to work on a particular day intending to cause harm. When things go wrong, we believe we can only learn and improve our practice in an environment and safe culture which is fair, just and compassionate – for everyone; patients, their families and carers and our colleagues.

“Using PSIRF may be a big change, but it is one that gives more opportunities to learn and inform improvements for how we care in the future. It will give us more data and information to help us make improvements. It will help us involve patients, families and carers and colleagues in reviewing what happened and then to focus on what we can improve rather than who is to blame.

“That helps us create an environment where people feel safe to raise concerns or to share when things have gone wrong knowing that they will be listened to fairly and in a compassionate way with a focus on how we can enhance our practice.”