What is PSIRF and what did it replace?
A patient safety incident is any unintended or unexpected event in healthcare that harmed, or could have harmed, one or more patients. PSIRF sets out how NHS organisations in England should respond to those events. It is part of the NHS Patient Safety Strategy and applies to NHS-funded care, with secondary care providers expected to move across from 2022 onwards.
Before PSIRF, the most serious incidents were handled under the Serious Incident Framework (last updated in 2015). Incidents were labelled "serious incidents" against thresholds, investigated with root cause analysis, and reports were sent to commissioners to be signed off. Over time, problems became clear. Investigations were often triggered by a threshold rather than by what could be learned, recommendations were frequently weak ("staff reminded"), and patients, families and staff often felt shut out or blamed.
| Serious Incident Framework | PSIRF | |
|---|---|---|
| Starting question | Does this meet the serious incident threshold? | What can we learn, and what is the best way to learn it? |
| Typical method | Root cause analysis | A range of system-based learning responses |
| Who decides the response | Mostly fixed national thresholds | The organisation's own plan, based on its safety data, plus national requirements |
| Oversight | Commissioners reviewing individual reports | Supportive oversight of whether the organisation is learning and improving |
| Involvement | Often limited | Patients, families and staff involved as a core aim |
What are the four aims of PSIRF?
The four aims explain almost every feature of the framework. They also come up in interviews and appraisals, so they are worth knowing in plain terms.
| Aim | What it means on the ward |
|---|---|
| Compassionate engagement and involvement of those affected | Patients, families and staff are treated kindly, kept informed and given a real chance to share their account and questions |
| A range of system-based approaches to learning | Reviews look at tasks, tools, environment and organisation, not just for a single root cause or a person to blame |
| Considered and proportionate responses | The type and size of response matches what can be learned, rather than treating every incident the same |
| Supportive oversight focused on improvement | Boards, integrated care boards and regulators check that the response system works and leads to change |
The policy and the plan
Each organisation publishes a patient safety incident response policy (its overall approach, including how it supports staff and involves families) and a patient safety incident response plan. The plan is built from the organisation's own data, such as incident reports, complaints, claims and mortality reviews. It sets local priorities and states which learning response will normally be used for each type of incident. This is why two trusts can respond differently to similar incidents and both be acting correctly. Your trust's plan is usually on its website or intranet.
What are the PSIRF learning responses?
You do not need to be an expert in every method, but you should recognise them and know what will be asked of you.
| Learning response | When it is used | What it involves for you |
|---|---|---|
| Swarm huddle | Straight after an incident, while memories are fresh | A short meeting near where it happened to share what you saw and agree immediate safety actions |
| After action review (AAR) | Soon after an event, including ones with good outcomes | A facilitated conversation around what was expected, what happened, why there was a difference, and what can be learned |
| Multidisciplinary team (MDT) review | To explore an incident or a group of similar incidents across professions | Explaining how the work is actually done in your role and where the system makes it hard |
| Thematic review | To find patterns across several similar incidents | Questions about how a common task is usually done, rather than about one event |
| Patient safety incident investigation (PSII) | National requirements and local priorities where in-depth learning is needed | Interviews, observation of work and a systems-based report with safety actions, led by trained investigators |
Many trusts also use the SEIPS model (Systems Engineering Initiative for Patient Safety) to look at the person, tasks, tools and technology, environment and organisation around an incident. A related idea is the gap between work as imagined (how the policy says a task is done) and work as done (how it really happens on a short-staffed shift). Learning responses want honest accounts of work as done, including workarounds.
Are serious incidents still investigated under PSIRF?
Yes. A common myth is that PSIRF means serious harm is no longer investigated. The change is that the response is chosen for its learning value. Some incidents still require a particular response whatever the local plan says. These include incidents meeting the Never Events criteria and deaths thought more likely than not to be due to problems in care (identified through Learning from Deaths). Other incidents go to other processes, for example certain maternity incidents to the national maternity investigation programme, child deaths to child death review, and safeguarding concerns to safeguarding procedures.
PSIRF learning responses are also not the place to decide blame, liability, avoidability or cause of death. Concerns about conduct, capability, criminal acts or deliberate harm are handled through separate processes, such as HR, regulators, coroners or the police.
What should you do straight after a patient safety incident?
Whatever framework your organisation uses, your first responsibilities do not change.
- Make the patient safe: Assess and treat any harm, call for help using your local emergency process, and remove or isolate faulty equipment or medicines.
- Escalate: Tell the nurse or person in charge and the responsible clinician so the plan, monitoring or environment can be changed.
- Be open with the patient: Tell the patient or those close to them what happened, apologise and explain what happens next. This is your professional duty of candour. An apology is not an admission of legal liability.
- Document factually: Write a clear, timed account in the record. Never alter earlier entries. Label anything added later as a late entry.
- Report it: Complete an incident report on your local system, including near misses. In England, local systems feed the national Learn from Patient Safety Events (LFPSE) service.
- Look after yourself and colleagues: Being involved in an incident can be distressing. Talk to your manager or supervisor and use staff support and wellbeing services.
What happens if you are asked to take part in an after action review or PSII?
These are learning conversations, not disciplinary hearings. Your organisation should explain the purpose, who will be there, how your account will be used and what support is available. If it has not, it is reasonable to ask.
- Re-read your own notes and any statement you wrote at the time.
- Describe what you did, what you noticed and what you were thinking then, not what you know now.
- Be honest about workarounds, pressures and missing equipment. That is where the learning is.
- Stick to facts. If you are unsure, say so.
- Talk about the system, not colleagues' personalities.
- Suggest practical fixes. Front-line staff often know them best.
- Ask how findings will be shared with you and with the patient or family.
Be aware of hindsight bias (the right decision looks obvious once you know the outcome) and outcome bias (the same decision is judged more harshly when the outcome is bad). A good review tries to understand what made sense at the time.
Is PSIRF a no-blame culture?
No. PSIRF supports a just culture, which is about fairness in both directions. Staff should not be blamed for system failures. Deliberate harm, dishonesty and reckless disregard for safety are still dealt with through disciplinary, regulatory or legal routes. NHS England's just culture guide helps managers decide whether someone needs support, learning or a separate process, using questions about intent, health, whether safe procedures were followed and workable, and whether a similar colleague would have acted the same way.
For you as an individual, PSIRF does not remove accountability. Regulators still expect you to be open, report incidents, take part in reviews and change your own practice where needed. The difference is that your reflection can now draw on a system-focused learning response, which usually makes it stronger.
Tomas, a physiotherapist covering two wards on a Saturday, mobilises a patient alone two days after hip surgery. Her assessment was updated that morning to two-person assistance, but the bedside board still said one. She becomes dizzy and slides to the floor, uninjured. Tomas makes her safe, informs the nurse in charge and the doctor, apologises to her and her daughter, and reports it. An after action review finds mobility status is recorded in three places, and that two similar near misses had already been reported. The agreed safety action is a single electronic mobility status linked to the bedside display, with a weekend therapy handover sheet in the meantime.
She slid to the floor but wasn't hurt. The board said one assist so I followed it. The nurses should have updated it. I'll be more careful.
I mobilised a patient alone when her updated assessment said two staff. I relied on the board because I was covering two wards and did not read the latest nursing entry. She could have fractured her new hip, and she and her daughter were frightened. The after action review showed mobility is recorded in three places and two near misses had already occurred. I now check the latest nursing and therapy entries before mobilising anyone whose status may have changed, I helped write the weekend handover sheet, and I will review its use with my clinical lead in three months.
Learning more about PSIRF
The Health Services Safety Investigations Body reported in October 2025 that staff broadly welcome the shift to system-based learning, but that skills and support vary between organisations. That makes it worth understanding the framework yourself rather than relying on your trust's induction alone.
Our course Patient Safety Incident Response Framework (PSIRF) covers the four aims, the learning response methods, how to contribute well to a review and how to turn an incident into a reflection that shows insight. If your incident involved medicines or records, Medication Errors: Reflection and Remediation and Record Keeping and Documentation: Remediation Course cover those areas in more depth. No course can decide the outcome of an employer or regulator process.
Frequently asked questions
What does PSIRF stand for?
PSIRF stands for the Patient Safety Incident Response Framework. It was published by NHS England in August 2022 and sets out how NHS-funded organisations in England respond to patient safety incidents. It replaced the Serious Incident Framework and is part of the wider NHS Patient Safety Strategy.
Has PSIRF replaced root cause analysis?
Largely, yes. PSIRF moves away from root cause analysis, which tended to look for a single cause and often produced weak actions. Instead it uses system-based methods, such as the SEIPS model, after action reviews and thematic reviews, which look at how people, tasks, tools, environment and organisation interacted to make an incident possible.
What is the difference between an AAR and a PSII?
An after action review (AAR) is a short facilitated conversation soon after an event, asking what was expected, what happened, why they differed and what can be learned. A patient safety incident investigation (PSII) is a detailed, systems-based investigation by trained investigators, used for national requirements and local priorities where in-depth learning is needed.
Do I have to attend a PSIRF learning response?
Regulators expect professionals to cooperate with reviews and investigations, and your employer's policy will usually expect it too. Learning responses are not disciplinary meetings. You can ask about the purpose, who will attend, how your account will be used and what support is available. If you have wider concerns, seek advice from your union or defence organisation.
Does PSIRF apply in Scotland, Wales and Northern Ireland?
No. PSIRF is an NHS England framework. The other UK nations have their own national approaches to managing and learning from adverse events. If you work outside England, follow your health board or trust's local policy and the relevant national guidance for that nation.
Are Never Events still investigated under PSIRF?
Yes. Incidents meeting the Never Events criteria are a national requirement for a patient safety incident investigation under PSIRF. NHS England has said it intends to replace the Never Events framework with an approach aligned to PSIRF, but until that happens the existing framework still applies. Check NHS England's current guidance.
Is PSIRF the same as a no-blame culture?
No. PSIRF supports a just culture, which aims to treat staff fairly. People are not blamed for system failures, but deliberate harm, dishonesty, reckless behaviour and criminal acts are still handled through separate disciplinary, regulatory or legal processes. Learning responses do not decide blame or liability.
Related courses
Patient Safety Incident Response Framework (PSIRF)
This course explains how NHS organisations in England now respond to patient safety incidents under the Patient Safety Incident Response Framework,…
Medication Errors: Reflection and Remediation
This course explains why medication errors happen, what you must do when one occurs, and how to show a regulator or employer that you have understood…
Record Keeping and Documentation: Remediation Course
This course explains what good clinical documentation looks like, why record-keeping concerns arise, and why altering or falsifying a record is…
Sources and further reading
- Patient Safety Incident Response Framework. NHS England.
- Engaging and involving patients, families and staff following a patient safety incident. NHS England.
- Never Events policy and framework. NHS England.
- A just culture guide. NHS England.
- Investigating under the Patient Safety Incident Response Framework (2025). Health Services Safety Investigations Body.
- Openness and honesty when things go wrong: the professional duty of candour. General Medical Council and Nursing and Midwifery Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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