Patient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe.
The Patient Safety Incident Response Framework (PSIRF) is followed by all NHS Trusts in England. This describes how to identify and respond to patient safety incidents.
EMAS has established a twice-weekly, multi-disciplinary Incident Review Group (eg senior clinicians) which meets to determine if the Trust response to an incident meets the criteria for reporting it as a PSII. All cases where there has been an adverse patient outcome (including death) and where there has been a delay in ambulance response, are reviewed. This includes a review of:
- the 999 call to check that the call was categorised correctly
- the actions taken by the ambulance dispatchers in the control room to ensure that protocols for dispatch were followed, and
- the ambulance resources available to attend at the time of the incident.
Not all patient safety incidents require an investigation and some of them may benefit from a different type of learning response under PSIRF such as an after-action review.
The purpose of a Patient Safety Incident Investigation (PSII) is to identify what happened and why, so that we can try to reduce the chances of it happening again, in this case by using a thorough, transparent open and honest investigation process. The patient, and/or their family are also invited to be involved in the investigation process as much as they wish to be and to contribute to the terms of reference for the investigation.
The investigation includes a review of both internal factors (eg ambulances available) and external factors (eg NHS and 999 demand/hospital handover delays) which impacted our ability to respond, and outcomes are shared with the families, our commissioners (eg NHS England and Integrated Care Systems) and regulators (eg Care Quality Commission).
We will look at the circumstances that led to the incident, and review procedures and practices, using a collaborative approach between NHS organisation to identify areas that need to be changed or improved. The purpose of this process is not to blame any individuals involved, but to listen, learn and make improvements where necessary. Everyone involved will be treated respectfully and with compassion.
Once the investigation process is complete, we begin to implement the action plan included in the report. The completion of these actions is monitored to ensure that we complete them within the specific timescales. The patient and/or their family are also provided with a copy of the report and hey are supported throughout the process by the Family Liaison Officer.