The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.
Moving away from the Serious Incident Framework, PSIRF and its supportive resources allow organisations to draw learning from all safety incidents with a more inclusive, compassionate response to investigation.

Embedding the principles of PSIRF throughout the culture of a Medicines Management team of an acute Trust is ultimately a test of leadership. Considering all safety incidents with the aim of identifying themes to prevent harm, necessitated a very different way of working. 

Regular triage of incidents with a multi-modal approach to learning has been pivotal in adherence to the framework and demonstrated the benefits in utilising PSIRF. 

Challenges have included:
1.    Resource: triaging incidents, thematic analysis, education and training, and having true oversight over learning takes much time.
2.    Situational leadership: directive leadership moving into supportive relationships with leaders throughout Pharmacy is a long-term effort. 
3.    Proportionate responses: with the array of reporting and investigation tools available, ensuring that each investigation is meaningful and necessary for learning has been an interesting challenge.

Progress so far:
1.    Small steps towards a learning culture: increased reporting, and engagement of pharmacy professionals in learning exercises is regular.
2.    Collaboration: sharing learning points from investigations with other specialties and organisations, thus allowing the extrapolation of learning.
3.    Structure established for escalation and communication of learning from patient safety events.