PSIRF Implementation Walkthrough

This resource, PSIRF Implementation Walkthrough, is part of our growing library of practical patient safety material. It is placeholder content for design and will be replaced with real copy.

Patient safety work rarely fails for a single reason. More often, outcomes emerge from the interaction of people, tools, processes and the wider system around them.

Why this matters

Taking a systems view means looking beyond individual actions to the conditions that shaped them. This shift in perspective is the foundation of meaningful learning.

When teams slow down to understand how work actually happens — rather than how it is imagined to happen — they uncover the most useful opportunities to improve.

Putting it into practice

• Involve patients, families and staff as partners in the process
• Separate understanding the problem from agreeing the response
• Capture contributing factors across the whole system
• Agree owners and timescales for every action

Key principles

Clear, proportionate responses help organisations focus their limited time and energy where it will make the biggest difference to patients and families.

1. Agree proportionate, owned actions
2. Review and share what was learned
3. Map what happened and who was involved
4. Explore the conditions and contributing factors

The goal is not to find someone to blame, but to understand the system well enough to make it safer.

Engaging those affected early and honestly is not just good practice; it consistently leads to richer insight and more durable change.

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