Patient Safety Incident Response Plan

Safety Starts with Me is about everyone's responsibility to learn from safety incidents and improve the safety of First Community for everyone that works here or uses our services.

Safety Starts with Me aligns with the National Patient Safety Strategy recognising the importance of improving safety across the whole system and giving everyone the skills and opportunity to improve patient safety.

Learning, involvement, the purple thread, speaking up. Introduction from Sarah Tomkins, First Community's Chief Executive and Executive Lead for Freedom to Speak up Guardians.

It is my pleasure to introduce First Community's Patient Safety Incident Response Plan for 1 April 2025 to 31 March 2026. Relationships and respect are at the heart of our plan and our ambition to provide First Rate Care by First rate People.  I am incredibly proud of our prioritisation on learning when responding to patient safety incidents. This approach has led to improvements and shared learning enabled by a sharper focus on our learning responses, learning responses that mean involvement of all of you is at the heart of how we learn.

First Community's Patient Safety Incident Response Plan sets out how we intend to respond to patient safety incidents over the next 12 months. The specific circumstances in which patient safety issues and incidents occur and the needs of those affected can change, therefore this plan may change as we learn and improve. 

We will remain flexible in our approach, using our weekly safety meeting to consider events, share learning and make decisions. The last 12 months has seen our weekly safety meeting grow in both the events being brought for discussion and attendance of colleagues. I take great pride in this, knowing that this essential part of our governance around learning has become a source of support and is enhancing First Community's culture of openness and transparency. I am pleased that 90% (compared to 84% in 2023) of colleagues that responded to the NHS Staff survey 2024 said First Community ensure incidents are not repeated.  This means we are sharing learning and remaining committed to the standards we have sent out in this plan.

Learning from patient safety incidents is about a culture where people feel they can speak up about anything that gets in the way of good care. I am proud to be First Community's executive lead for speaking up and I encourage everyone to speak up and give you the commitment that we will listen.  87% of you who responded to the NHS Staff Survey in 2024 said you felt secure to raise concerns about unsafe practice. By speaking up at work colleagues will be playing a vital role in helping us to keep improving and learning, keeping patients safe and creating a safe working environment for everyone. This plan helps us continue on that journey to being an organisation that lives and breathes a safe culture in which people feel safe to speak up, where speaking up is business as usual. We are employee owned, and this plan enables us to remain true to our founding principle of being clinically led, continuously learning and improving.

The foundations of this plan align to our strategic plan and approach, and you can see this clearly on the next page. 
I look forward to the next 12 months as we continue to focus our support and energy towards a shared vision for patient safety, taking this plan forward, learning and improving, supporting each other to speak up, learn, listen and improve.

Vision: To work in partnership with people living and working in our community to deliver outstanding lifelong local NHS healthcare, supporting everyone to achieve their potential.

1. Our services

Click here to view our services

2. Focus on Improvement and Learning

Improvement and learning from patient safety incidents, including the locally defined priorities in section five, will address the five recognised stages of Quality Improvement as stated below.

Defining clusters of patient safety incidents and our patient safety incident profile, as detailed in this plan, has allowed us to identify and begin to understand the problem for each patient safety incident issue.

First community will bring together safety learning responses and quality improvement tools to enable continuous learning and improvement. Appropriate measures to test the effectiveness of any planned actions will be identified. Implemented actions will be reviewed using these measures to evaluate their impact on the patient safety incident issue and determine whether they should be adapted, adopted or abandoned.

It is important that others can learn from these pieces of improvement work to support more wide-spread learning and change. Learning will be shared at First Community's Clinical Quality and Effectiveness Group, at quarterly Patient Safety Incident Response Framework (PSIRF) meetings, through the QI Leaders Network, project reporting posters and First News and at First Community's annual Quality Improvement Day to maximise organisation-wide learning.

2.1 Using our Quality Improvement approach to deliver this plan

Definitions: 

 

Patient Safety Incident Investigation (PSII): A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
B1465-PSII-overview-v1-FINAL.pdf (england.nhs.uk)

 

Learning from Lives and Deaths: People with a Learning Disability and autistic people (LeDeR): A LeDeR review looks at key episodes of health and social care a person has received looking for areas that need improvement and where practice has been good.

 

Post Infection Review (PIR): A review into the circumstances surrounding specific infections to find out improvements, learning and share good practice.

 

After Action Review (AAR): A method of evaluation to capture outcomes of an activity or event, aiming to capture learning and promote success for the future. learning-handbook-after-action-review.pdf (england.nhs.uk)

First Community staff can access the the GU_PSQ061a After Action Review-Conductors Toolkit v1 and GU_PSQ061b After Action Review: Information for People Participating v1 documents for further information. 

 

SWARM Huddle: Immediately after an incident, staff 'swarm' to the site to find out what happened, how it happened and decide on actions to reduce the risk of recurrence. B1465-Swarm-huddle-v1-FINAL.pdf (england.nhs.uk)

First Community staff can access the GU_PSQ061e Swarm Huddle TOOL v1 document for further information. 

 

Multidisciplinary Team Review: An open discussion to identify key factors and gaps in patient safety incidents for which it is more difficult to collect staff recollections of events either because of the passage of time or staff availability or where there are multiple safety incidents. B1465-MDT-review-v1_FINAL.pdf (england.nhs.uk)

First Community staff can access the GU_PSQ061c Multidisciplinary (MDT) Review TOOL: v1 document for further information. 

The diagram below demonstrates how First Community's Patient Safety Responses and plan will be integrated into our quality improvement approach. 

3. Defining our Patient Safety incident and improvement profile

The patient safety incident risks for First Community have been profiled. This has been completed both at service level and at an organisational level. During the period 1 April 2024 to 31 March 2025 First Community have undertaken two Patient Safey Incident Investigations (PSIIs). We know that the most frequent reported incidents continue to be falls, pressure ulcers and medicines. However, that does not mean these will provide the most learning and opportunity for improvement. To define our priorities, the patient safety and quality team met with every service to collaboratively review their data. This enabled an open conversation about risk and maximising resources to enable safety improvement and learning. 

The following data sources for the previous 12 months has been used at service level and organisational level:

As well as meetings with all clinical services in First Community the following stakeholders were involved:

• Adult Safeguarding Lead
• Accountable Director for Safeguarding Adult and Children
• Quality Improvement and Patient Safety Lead
• Patient Safety Partner
• Clinical Governance Manager
• Freedom to Speak up Guardian
• Learning and Development Lead
• Head of People Services
• Lead Nurse for Patient Safety and Infection Prevention and Control
• Head of Medicines Management
• Council of Governors Representative

First Community acknowledges that our patient safety incident and improvement profile may change over time. Therefore, we have implemented processes to ensure that any emerging priorities are identified, at both a service level and an organisational level, to enable safety improvement and learning.

The following data sources will be used at service level and organisational level.

First Community's Quality Committee (Board oversight of Quality) and Clinical Quality and Effectiveness Group (Operational oversight of quality reporting to Quality Committee) hold the authority for the implementation of PSIRF and development of this plan and First Community's Patient Safety Incident Response Policy. This group includes First Community's Patient Safety Partner as a core member to champion the patient voice in the development of this plan. 

First Community is committed to clinically led continuous improvement and has embedded annual quality improvement planning which plans improvement activity annually. The governance and reporting framework for quality improvement ensures learning is shared and that improvement is made and sustained. Plans are flexible and are informed by listening and involvement of those who use our services to enable in year modification to respond to arising risks, feedback and incidents.

Planned improvement for the period 1 April 2025 to 31 March 2026 includes the following work that impacts on safety learning and improvement:

4. Our patient safety incident response plan: national requirements

Below is a list of patient safety incidents that will be responded to according to national requirements. There will be responses that First Community will lead or be part of involving other partner organisations. Where this is the case First Community will be responsible for the governance around their own actions only. It must be clear in terms of reference or ground rules that each organisation is responsible for implementation and governance of actions. Any actions identified to be enacted by another provider or stakeholder must be discussed with the relevant provider / stakeholder and / or commissioner.

Surrey Heartlands ICB can be involved to maintain oversight depending on the nature of learning and stakeholders involved.

Leading a multi-provider response may be overseen by Surrey Heartlands ICB depending on the nature of learning and stakeholders involved. First Community will alert Surrey Heartlands ICB in the event of a multi-provider learning response, as appropriate.

Patient safety incident type	Required response	Anticipated improvement route
Incidents meeting the Never Events criteria	PSII	Clinical Quality and Effectiveness Group
Death thought more likely than not due to problems in care (incident meeting the learning from deaths criteria for patient safety incident investigations (PSIIs))	PSII	Mortality Review Group
Death of a person with learning disabilities where there is reason to believe that the death could have been contributed to by one or more patient safety incidents/problems in the healthcare provided by the NHS.	PSII LeDeR Review	Mortality Review Group
Incidents with Safeguarding Responsibilities where a concern of abuse or neglect has been identified.	As per safeguarding requirements	Safeguarding Group
Infections Prevention and Control Outbreak Notification of Infectious Disease	PIR PSII AAR	Infection Prevention and Control Group

First Community have determined our local focus based on stakeholder engagement and findings of our local mapping and profiling. Below is a list of patient safety incidents that will be responded to for learning and improvement:

Patient safety incident type or issue	Planned response	Anticipated improvement	New or ongoing priority for learning and improvement
Caterham Dene Ward - Improving communication with relatives	AAR Multidisciplinary Team Review	Improve communication between patients, those close to them and the ward staff	New priority for 2025-2026
Violence, aggression and abuse - keeping staff safe	AAR Multidisciplinary Team Review	Reduce the risk of violence, aggression and abuse towards staff, keeping our staff safe	New priority for 2025-2026
Primary Care Networks - Safer administration of insulin	Multidisciplinary Team Review AAR	Safer administration of insulin for people living in their own homes	Priority carried over from 2024-2025
Caterham Dene Ward - Falls Group	AAR	Reduce the risk of falls on Caterham Dene Ward	Priority carried over from 2024-2025
Caterham Dene Ward -Administration of PRN (as required) controlled drugs	AAR	Improve the process for administering controlled drugs given as required, increasing the timeliness for patients.	Priority carried over from 2024-2025
Other incidents which have resulted in moderate to severe harm, a near miss, or where there is potential for wider learning	Duty of Candour AAR PSII	To identify risk and learning in real-time	N/A
Clusters of incidents	Multidisciplinary Team Review	To identify risk and learning in real-time	N/A
Good or positive care or event	Multidisciplinary Team Review AAR	To identify learning in real-time	N/A
Cross System or multi organisation patient safety incidents	Where more than one organisation is involved in a patient safety incident, the organisation that identifies the incident is responsible for alerting relevant stakeholders to commence investigation and action.	N/A

A detailed explanation of the various learning response methods available to us can be found in Appendix A.

Appendix A: Learning Response Methods Available

Response Method	Description	When to use	Who can lead this	Who should be involved	Time taken to complete
After Action Review (AAR)	An after-action review (AAR) is a structured approach for reflection and identifying strengths, weaknesses and areas for improvement. It is a facilitated discussion following an event or activity to enable understanding of the expectations and perspectives of all those involved. AAR is recommended as a key tool to bring about learning and improvement in the Patient Safety Incident Response Framework (PSIRF).	First Community have chosen AAR as the main model to learn from incident responses, learning from excellence and other improvement work.   An AAR can be used after any activity or event that has been particularly successful or unsuccessful.	Any trained conductor	This is identified as part of each AAR. Can be those involved, others involved in the process and multidisciplinary team and service users.	Between 45 and 90 minutes then time to write up the AAR.
Multidisciplinary Team Review (MDT Review)	A multidisciplinary (MDT) review is a structured approach for reflection and identifying learning from multiple patient safety incidents or a safety theme. It is a facilitated discussion to enable insights into 'work as done' from all those involved and contributes to the understanding the problem step of Quality Improvement projects.  MDT reviews are recommended as a key tool to bring about learning and improvement in the Patient Safety Incident Response Framework (PSIRF). NHS England » Patient safety learning response toolkit	An MDT review can be used after when there are multiple, similar incidents or to explore a safety theme, pathway or process e.g. admission or discharge related safety events.	Usually someone who has completed training provided by First Community and / or SEIPS.	The stakeholders whose insights on 'work as done'. This list will depend on the incident or safety theme being explored. It should include clinical and non-clinical staff who work in the care setting or pathway to which you are applying the tool.	Each MDT review is different. Likely to be 2-3 hours and be run as a workshop type event.
Patient Safety Incident Investigation (PSII)	A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time.	When an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation.	A Learning Response Lead. This is a member of staff who has completed the relevant training and is competent to undertake a PSII. A lead will be nominated by the Safety Huddle.	The investigation team should be formed based on factors including availability, systems-focused safety investigation knowledge and interests.	Up to 80 hours (not all at the same time) and will take a number of weeks to complete.
Swarm huddle	A swarm huddle is a post-incident huddle which explores what happened and how it happened in the context of how care was being delivered in the real world (ie work as done) to allow us to learn and improve.   Swarm huddles are recommended as a key tool to bring about learning and improvement in the Patient Safety Incident Response Framework (PSIRF).   NHS England » Patient safety learning response toolkit	A swarm huddle takes place as soon as possible after a patient safety incident occurs allowing safety actions to be implemented immediately.	Usually someone who has completed training provided by First Community and / or SEIPS.	Those directly involved in these events. Can also include others involved in the process and multidisciplinary team and service users.	Up to 30 minutes and then time to write up learning.

For office use only:

Start Date	1 April 2025	End Date	31 March 2026
Approved by:	Clinical Quality and Effectiveness Group	Responsible Executive	Jon Ota, Director of Quality and People and Chief nurse
Ratified by:	Quality Committee	Version	2.1 DRAFTFor office use only: