Helping health and care partners turn patient safety learning into improvement

The System Safety Improvement Programme has been refreshed for 2026/27. The programme will support health and care partners across the West of England turn learning from patient safety incidents into practical, measurable improvement.

The programme supports the Patient Safety Incident Response Framework (PSIRF), which is the NHS approach to responding to patient safety incidents for learning and improvement —this approach was implemented in April 2024 following a two-year pilot programme, and replaced the previous Serious Incident Framework.

PSIRF is a requirement for services provided under the NHS Standard Contract, including acute, ambulance, mental health, community, maternity and specialised services.

PSIRF is built around four priorities:

  • Compassionate involvement: involving patients, families, carers and staff affected by patient safety incidents.
  • System-based learning: understanding how care is delivered in real life, including the wider factors that help or hinder safe care.
  • Proportionate responses: responding to incidents in a way that is appropriate to the learning and improvement needed.
  • Supportive oversight: helping leaders and organisations strengthen learning, improvement and safety management.

 

In 2026/27, our programme will focus particularly on system-based learning and supportive oversight.

This means we will work with Integrated Care Boards, NHS providers, regional teams and other partners to understand how safety learning moves through local systems. We will look at how patient safety, quality improvement, governance, commissioning, patient experience and clinical teams work together to turn insight into action.

We will also support leaders to create the conditions for improvement. This includes strengthening relationships, connecting existing networks, identifying gaps in improvement capability, and supporting system-level plans linked to local safety priorities.

The aim is to help partners move beyond learning about what happened, towards understanding why it happened, what needs to change, and how improvement can be sustained across the health and care system.

Why this matters

Patient safety learning is most useful when it leads to action.

PSIRF encourages organisations to understand how incidents happen, involve those affected (patients, families and staff), respond proportionately and focus on improvement rather than blame.

National patient safety learning reviews consistently demonstrate that risks often sit across organisational boundaries. Patients may receive care from several teams, services or organisations, so safety improvement often needs a shared system approach.

What is changing in 2026/27?

In 2026/27, the programme will focus on moving from PSIRF implementation to insight to improvement.

This means we will work with partners to understand how learning from patient safety incidents is used, what helps improvement to happen, and what can get in the way. We will also support stronger links between patient safety, quality improvement, governance, commissioning, patient experience and clinical teams.

The aim is to help local systems build the relationships, networks and improvement infrastructure needed to make care safer for patients.

During 2026/27, Health Innovation West of England will work with local and regional partners to:

  • build a shared picture of local patient safety and improvement activity
  • identify the people, teams and networks involved in turning learning into improvement
  • understand gaps, barriers and opportunities across local systems
  • support stronger connections between patient safety and quality improvement teams
  • help leaders understand their role in enabling a positive learning culture
  • support peer learning between organisations and systems
  • help partners develop practical improvement plans linked to local safety priorities
  • share learning, case studies and examples of improvement across the West of England

Get involved and resources

Sirona Care and Health have produced a case study on LFPSE (Learn from Patient Safety Events) and PSIRF Implementation. Sirona were early implementers for the LFPSE system; this case study outlines how utilising this system for reporting has supported the transition to PSIRF.  Read the case study here.

If you are involved in patient safety, quality improvement, governance, commissioning, clinical leadership or patient involvement, we would like to hear from you.

We are particularly interested in:

  • what helps your organisation turn learning into improvement
  • what makes improvement difficult
  • examples of good practice that others could learn from
  • how patients, families, carers and staff are involved in learning and improvement

For more information, please contact our patient safety team.

Register for the PSIRF discussion forum where you can ask questions and share your experiences with people in organisations across England working to prepare for PSIRF.

Please visit our events listings to find details of all patient safety events.

You can also stay up to date with our news and events by signing-up to receive our monthly newsletter.