NHS to move away from blame culture in patient safety incidents

  • Date: 25 August 2022

THE NHS should focus on learning from patient safety incidents rather than looking to blame individuals, according to a major new piece of guidance.

NHS England has published its Patient Safety Incident Response Framework (PSIRF) which offers guidance on how NHS organisations respond to patient safety incidents.

The framework represents “a significant shift” in the way the NHS responds to patient safety incidents, and seeks to move away from a culture of blame.

It is centred on:

  • compassion and involving those affected
  • system based approaches to learning and improvement
  • considered and proportionate responses
  • supportive oversight.

NHS England described PSIRF as a “major step towards improving safety management across the healthcare system in England.”

Published alongside the framework, the Guide to engaging and involving patients, families and staff following a patient safety incident, also sets out expectations for how those affected by an incident, such as patients, families and staff, should be treated with compassion and involved in any investigation process.

The guide was co-authored by HSIB, Learn Together and NHS England.

Louise Pye, Head of Family Engagement at HSIB, said: “Effectively involving patients, their families and NHS staff is fundamental to bringing about safety improvements. I hope [this guide] provides a consistent and meaningful approach to those impacted by patient safety incidents.”

The guidance has been welcomed by Dr Sean O’Kelly, Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services, at the Care Quality Commission.

He said: “[W]e have seen how the existence of a strong organisational safety culture, where the views of staff and patients are listened to and acted on, and learning is prioritised is essential to good practice in responding when things go wrong.”

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