Systems Approach to learning from patient safety incidents (PSIRF)

Duration : 13 Hours over 2 days Accreditation : 12 CPD

Venue: online or face to face 

This course is for anyone who might be involved in conducting investigations in healthcare. The focus of the course is the implementation of the new Patient Incident Response Framework (PSIRF) and has a very practical approach to learn the skills required to undertake a System Based Investigation

The course follows and endorses current NHS Patient Safety Incident Investigation (PSII) guidance and teaches recognised good practice approach(es) to systems based PSIIs and is based around case scenarios and on developing the practical skills required to undertake investigations whilst considering Human Factors and supporting families and staff as well as service users.

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Systems Approach to learning from patient safety incidents (PSIRF)


Accredited by:CPD


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This two-day intensive masterclass will provide Investigation Skills Analysis Training in line with the 2019 Patient Safety Strategy and Patient Incident Response Framework (PSIRF) the course focus is on understanding that healthcare systems that are founded on human factors principles can positively impact on safety by:

Reduction of harm through better design of healthcare systems and equipment

Understanding why staff may make errors and how “systems and human factors’ threaten safety

Enhancing teamwork and improving communication between healthcare staff.

Improving how we learn when things go wrong by improving current approaches to incident investigation.

This course is designed to provide delegates with the tools and knowledge required to begin leading healthcare investigations. It also strives to examine the difficulties with this process and the importance of placing human factors at the heart of incident investigation.

Programme Objectives and course content
Overview of a “Systems approach to investigation and learning”

  • To understand the requirements of the new Patient Incident Response Framework (PSIRF) and the difference with the previous system

  • To learn key concepts and terms involved in the new Patient Incident Response Framework

  • To have an understanding of Duty of Candour

  • To understand the impact of Human Factors on adverse events

  • Gain an understanding of systems frameworks; Introduction to Systems Engineering Initiative for Patient Safety (SEIPS)

  • The importance of Organisational Factors. – “Just Culture”

    The Investigation Process and management

  • Using SEIPS to GUIDE investigations.

  • Involving Patients and Families and engaging with staff

    Investigation Skills

• Systems Approach to investigations

  • Managing and Analysing Evidence

  • How to arrive at meaningful recommendations which can be actioned by the team.

  • To understand how to generate effective improvement/solution generation and implementation.

  • To be able to write a robust report of the findings of the investigation to inform colleagues, managers and others including the coroner as required.

    The course is based around case scenarios and on developing the practical skills required to undertake investigations whilst considering Human Factors and supporting families and staff as well as service users.