Development of systems-based tools for learning from patient safety incidents

The Patient Safety Incident Response Framework (PSIRF) is a key part of the NHS Patient Safety Strategy. It aims to significantly enhance the quality of learning and improvement following patient safety incidents.

This project will require an initial overview of currently available tools and resources for complementary methods to investigation. Based on the learning from this scoping exercise we anticipate the development of new or refreshed tools to prompt systems thinking and a standardised approach to the application of a variety of tools/techniques to support learning from patient safety incidents using complementary methods to traditional incident investigations.

We expect a minimum of five tools to be created including tools to perform After Action Reviews, debriefs and safety huddles. These tools must be tested with representative users to validate the usability of the design.

The work must be completed by 31 March 2022.

NHSEI wishes to commission an England-wide review of the role and expectations of MVPs (including in relation to parents of babies in neonatal units), arrangements for the remuneration and claiming of expenses by SUV members and issue good practice guidance to commissioners of MVPs. The guidance should give clear, concise and practical suggestions to commissioners about reasonable expectations of MVPs and effective support arrangements (including remuneration). The guidance should reflect the varying operating conditions, e.g., urban vs rural, Local Maternity Systems with single providers and or multiple providers/maternity unit sites.