{"id":11172,"date":"2026-06-23T15:33:24","date_gmt":"2026-06-23T14:33:24","guid":{"rendered":"https:\/\/www.rldatix.com\/en-uki\/?p=11172"},"modified":"2026-06-23T21:00:21","modified_gmt":"2026-06-23T20:00:21","slug":"from-learning-from-incidents-to-psirf-driven-quality-improvement","status":"publish","type":"post","link":"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/","title":{"rendered":"From Learning from Incidents to PSIRF-Driven Quality Improvement\u00a0"},"content":{"rendered":"\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"1600\" height=\"900\" src=\"https:\/\/www.rldatix.com\/en-uki\/wp-content\/uploads\/sites\/6\/2026\/06\/Barts-Learning-Shortlisted.svg\" alt=\"\" class=\"wp-image-11425\"\/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\">Summary<\/h2>\n\n\n\n<p>The Division of Medicine at Whipps Cross Hospital began strengthening learning from incidents before COVID, relaunching the work in 2025 alongside PSIRF. A structured pathway was developed to turn PSIRF learning, cardiac arrest reviews and patient feedback into practical quality improvement. Each month, closed investigations and near misses were triaged against PSIRF priorities to ensure&nbsp;equitable&nbsp;learning across wards. Ward leaders shared learning through a dedicated forum, with recurring themes translated into teaching and improvement projects, creating a clear link between patient safety incidents, organisational&nbsp;learning&nbsp;and action.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">The Challenge<\/h2>\n\n\n\n<p>Learning from incidents in the Division of Medicine was fragmented and not consistently translated into frontline improvement. PSIRF learning responses, cardiac arrest reviews, complaints and near misses were often managed separately, limiting opportunities to&nbsp;identify&nbsp;shared themes and act on them. At the same time, wards were under significant pressure from patient flow, workforce shortages, deteriorating&nbsp;patients&nbsp;and complex decisions around escalation and DNACPR. Recurring issues, including delayed recognition of deterioration, inconsistent SBAR escalation, poor transfer communication and gaps in documentation, risked contributing to avoidable harm. Staff also reported fatigue with investigation processes that rarely led to visible change, affecting engagement and safety culture. The challenge was to create a sustainable, psychologically supportive approach that aligned PSIRF priorities with divisional risks, built staff confidence in quality improvement, and enabled learning to be turned into practical, achievable changes to care,&nbsp;training&nbsp;and systems.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">The Solution<\/h2>\n\n\n\n<p>A structured divisional process was introduced to connect PSIRF learning directly to quality improvement. Closed investigations, cardiac arrest reviews, complaints and near misses were filtered, themed and aligned to PSIRF and divisional priorities. Ward managers were supported with a standardised template and shared learning through a monthly Divisional Learning from Incidents forum, creating greater consistency,&nbsp;equity&nbsp;and shared ownership across wards. Findings were triangulated across sources and translated into improvement plans, teaching&nbsp;programmes&nbsp;and emerging QI projects. System tools, including SIEPS fishbone analysis, helped teams explore contributory factors such as human factors, organisational&nbsp;pressures&nbsp;and technology gaps. Learning was also linked directly to education through simulation, SBAR focus groups and deterioration study days, while PSIRF outputs were used to inform local improvement work. This shifted the focus from investigation alone to practical, team-led change in everyday clinical practice.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Results &amp; Next Steps<\/h2>\n\n\n\n<p>This work has created a visible and sustainable link between learning and improvement across the Division of Medicine. In 2025, the team reviewed and shared learning from 18 cardiac arrest cases, 13 complaints, multiple PSIRF learning responses and a range of near misses, helping to embed a more open and consistent approach to improvement. The work has strengthened staff capability in quality improvement, supported local and divisional QI projects, and led to practical changes in education,&nbsp;documentation&nbsp;and clinical processes. These include a structured deterioration study day,&nbsp;a sustained 10% improvement in DNACPR consultant validation compliance, better next-of-kin and emergency contact processes, and testing of tools to improve&nbsp;timely&nbsp;risk assessment documentation. It has also increased psychological safety, multidisciplinary&nbsp;learning&nbsp;and confidence that incident reporting leads to action. Interest from across the hospital is now supporting the development of a wider learning forum and shared resources to sustain and spread this approach.&nbsp;<\/p>\n\n\n\n<p><a href=\"https:\/\/www.rldatix.com\/en-uki\/every-voice-counts\/\">Back to Every Voice Counts<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Summary The Division of Medicine at Whipps Cross Hospital began strengthening learning from incidents before&#8230;<\/p>\n","protected":false},"author":40,"featured_media":11250,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":true,"inline_featured_image":false,"footnotes":""},"categories":[67],"tags":[255,263,379],"class_list":["post-11172","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-studies","tag-every-voice-counts","tag-learning-and-improvement-through-incident-reporting","tag-rld-awards-2026","primary-category-case-studies"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>From Learning from Incidents to PSIRF-Driven Quality Improvement\u00a0 | RLDatix<\/title>\n<meta name=\"description\" content=\"Health &amp; care resources from RLDatix: From Learning from Incidents to PSIRF-Driven Quality Improvement\u00a0. 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Insights, guidance and best practice for patient safety and operational improvement.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/\" \/>\n<meta property=\"og:site_name\" content=\"UK &amp; Ireland\" \/>\n<meta property=\"article:published_time\" content=\"2026-06-23T14:33:24+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-06-23T20:00:21+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.rldatix.com\/en-uki\/wp-content\/uploads\/sites\/6\/2026\/06\/awards2026-Barts-Health-NHS-Trust2.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"810\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Maithili Satam\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@rldatixuki\" \/>\n<meta name=\"twitter:site\" content=\"@rldatixuki\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Maithili Satam\" \/>\n\t<meta name=\"twitter:label2\" content=\"Estimated reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/\"},\"author\":{\"name\":\"Maithili Satam\",\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/#\/schema\/person\/b2456f4a5a1147acb653dd49b02c52d2\"},\"headline\":\"From Learning from Incidents to PSIRF-Driven Quality Improvement\u00a0\",\"datePublished\":\"2026-06-23T14:33:24+00:00\",\"dateModified\":\"2026-06-23T20:00:21+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/\"},\"wordCount\":564,\"publisher\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/#organization\"},\"image\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.rldatix.com\/en-uki\/wp-content\/uploads\/sites\/6\/2026\/06\/awards2026-Barts-Health-NHS-Trust2.webp\",\"keywords\":[\"Every Voice Counts\",\"Learning and Improvement Through Incident Reporting\",\"RLD Awards 2026\"],\"articleSection\":[\"Case Studies\"],\"inLanguage\":\"en-GB\"},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/\",\"url\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/\",\"name\":\"From Learning from Incidents to PSIRF-Driven Quality Improvement\u00a0 | RLDatix\",\"isPartOf\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/#primaryimage\"},\"image\":{\"@id\":\"https:\/\/www.rldatix.com\/en-uki\/resources\/from-learning-from-incidents-to-psirf-driven-quality-improvement\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.rldatix.com\/en-uki\/wp-content\/uploads\/sites\/6\/2026\/06\/awards2026-Barts-Health-NHS-Trust2.webp\",\"datePublished\":\"2026-06-23T14:33:24+00:00\",\"dateModified\":\"2026-06-23T20:00:21+00:00\",\"description\":\"Health & care resources from RLDatix: From Learning from Incidents to PSIRF-Driven Quality Improvement\u00a0. 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