Document

Author
Tracey A Herlihey, Lauren Mosley & Matthew Fogarty
Abstract
Any policy developed in a siloed manner and presented for implementation in a straightforward way is limited in its application in complex systems such as healthcare. In this article we describe a process for developing new patient safety policy by taking a user-centred approach and applying a system-based framework. The Patient Safety Incident Response Framework published in 2022 (NHS England, 2022), represents a complete redesign of how the NHS responds to patient safety incidents for the purpose of learning and improvement. The Framework will replace the current Serious Incident Framework (NHS England, 2015). Testing and revision were a formal part of the development cycle. The final version incorporates findings from an early adopter programme and independent evaluation and used SEIPS as a framework specifying the structure of a patient safety incident response system. We found the framework to be a useful tool for informing the revision of PSIRF; however, translating this work into policy form proved difficult and some nuance and direct links to SEIPS may have been lost.