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Systems and culture

Evaluating the patient safety incident response framework  


In August 2022, NHS England launched a new way of responding to safety events, called the Patient Safety Incident Response Framework (PSIRF). The PSIRF policy aims to support NHS organisations to be more flexible in how they respond to safety events. This is a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS.  

The PSIRF is a key part of the NHS patient safety strategy, supporting the development and maintenance of an effective patient safety incident response system. One of the key changes under the new policy is that NHS organisations no longer need to investigate every event that results in harm. 

The study aims to find out in real time how the roll out of this new policy happens across the NHS in England, and what impact it has. This will help to influence the way that patient safety policies are developed and launched in the future. It will combine a range of diverse types of research, examining how the policy works broadly across the NHS and in depth at a range of NHS organisations.  

The study is led by Jane O’Hara from THIS Institute and Carl Macrae of the University of Nottingham, and includes academic collaborators from the universities of Leeds, York, Bangor and Stavanger.  


We want to check if the metrics and monitoring methods are valid, identify any challenges in understanding them, and see how useful they are for understanding fairness and equity in safety event responses. To do this, we’ve set up a panel of up twenty-five patient safety specialists from organisations that vary in terms of size, sociodemographic factors, organisation type and region. 

The study began in May 2022 and will end in Summer 2025, and is supported by two stakeholder groups:  

  1. Citizens’ Panel: Engaging those affected by PSIRF   
  1. Patient Safety Panel: Engaging those implementing PSIRF 

Introducing the Patient Safety Incident Response Framework:

Additional co-investigators

  • Lorelei Jones – University of Bangor  
  • Rebecca Lawton – University of Leeds  
  • Laura Sheard – University of York  
  • James Titcombe – Independent Patient and Public Involvement & Engagement Advisor  
  • Siri Wiig – University of Stavanger  
  • Suzette Woodward – Independent Patient Safety Consultant 

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Jane O'Hara

Funding and ethics 

This project is funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR133742). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.  

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