To support the NHS to further improve patient safety, all NHS Trusts and providers are preparing for the introduction of a new Patient Safety Incident Response Framework (PSIRF).
We responds to patient safety incidents according to PSIRF. We recognise and acknowledge the significant impact patient safety incidents can have on patients, service users, their families, and carers.
We will use a variety of ways to identify learning and make improvements following an incident where a patient or service user was or could have been harmed.
This is a major step towards establishing a safety management system across the whole of the NHS.
The PSIRF supports the development and maintenance of an effective patient safety incident response system that brings together four aims:
- Compassionate engagement and involvement of those affected by patient safety incidents
- The application of a range of system-based approaches to our learning from patient safety incidents
- Considered and proportionate responses to patient safety incidents
- Supportive oversight which focusses on strengthening responses and system improvements.
At Mersey Care, our Patient Safety team are leading the PSIRF implementation to make sure that our work links with the wider health and care system.
Our culture of openness, honesty and transparency
Mersey Care is committed to delivering safe, high quality care. However, we also recognise that healthcare is complex, and situations can change rapidly or unexpectedly.
On occasion, things do not go to plan, despite our best intentions and safety checks being in place. A patient safety incident is any unintended or unexpected incident which has or could lead to harm for one or more patients receiving healthcare. These can range from incidents which cause no harm – such as a missed dose of a medicine - to rarer incidents which can have a devasting impact on someone’s life.
A legal Duty of Candour reinforces our principles of being open and involving our patients in the delivery of their care as part of our Restorative Just and Learning Culture. The statutory duty asks that healthcare providers make sure that patients or service users are told openly, honest and in a timely manner when mistakes happen which are believed to have caused significant harm. If a patient lacks capacity to make a decision regarding their own care or is deceased, then we should involve their families, or those close to them, in these discussions.
We are committed to talking to our patients, service users, families and carers at a very early stage to allow us all to understand what has happened and, where necessary, learn to prevent harm happening again as a way of improving the safety of our future patients and service users.
How will I know if a patient safety incident has occurred?
Mersey Care will always be open and honest about incidents that have occurred and this includes where we have a Duty of Candour. If it is believed that something has not gone as planned during your care that has caused you significant harm (this includes psychological harm), you will be told about this immediately. You will also receive an apology and the circumstances of the incident will be explained to you. This will usually be the doctor, nurse or other healthcare professional looking after the patient or service user. Your family/a friend can attend this meeting and be part of these conversations
For incidents that are not complex, we may be able to easily explain the circumstances and reach an understanding of what happened. For more complex reviews, we will offer you support to participate. This will be with a dedicated member of staff who can keep you informed of progress along the way.
When we undertake such a review we will:
- Firstly, ask you how much you, your relatives/carers wish to be involved in the review process
- Talk to you and our staff involved to gain a shared understanding of the incident. We will support you to ask questions that you need to, so you can be confident we have understood your views and experience
- Review your medical and nursing notes and any other useful documents
- Consider all the factors that might have led to the incident
- Share our findings with you or your family and carers
- Share any learning and make improvements to our systems and processes to keep our future patients and service users safe.
You can find out more about statutory Duty of Candour on the Care Quality Commission website. More information about Mersey Care's commitment to a Duty of Candour can be found in the Trust's policy.
A guide to PSIRF is available to read.
We recently recruited 2 Patient Safety Partners (PSPs)to support our patient safety work by making sure the patient’s voice is heard throughout our processes. This is a new role which will develop over time and we will consider whether further PSP recruitment is needed to support the patient safety work in Mersey Care. To learn more about what their role entails and view details for possible future recruitment, go to https://www.merseycare.nhs.uk/PSP