Cornwall Partnership NHS Foundation Trust as an early adopter of the patient safety incident response framework (PSIRF) has developed alongside key stakeholders a patient safety incident response plan (PSIRP) which sets out how we will respond to patient safety incidents reported by staff and patients, their families and carers as part of work to continually improve the quality and safety of the care provided. The plan sets out the ways the Trust intends to respond to patient safety incidents to learn and improve through patient safety incident investigations (PSIIs) and patient safety reviews (PSRs).
The Trust has identified the following events that we intend to investigate selected cases through a PSII:
Resource for a few additional PSIIs has also been allocated for any significant unexpected trend in incidents that could not have been foreseen as part of this planning exercise.
We would also undertake a number of PSII’s on national priorities which include:
Deaths that had previously been investigated as serious incidents under the 2015 framework will be reviewed in line with the learning from deaths national priority, during the review process certain incidents may proceed as a PSII.
In the years ahead, the trust will seek data and insight from stakeholders to inform potential future categories for local patient safety incident investigation and system improvement.
NHS England have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient
Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed.
Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip.
Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication.