What Have We Got Left to Learn About Safety in Paediatric Surgery?
The Patient Safety Incident Response Framework (PSIRF) represents a huge shift in how we learn about safety incidents in our organisations. Moving away from the blame-focused culture of the past, PSIRF fundamentally changes our approach from asking "who did what wrong?" to "how did our system allow this to happen?" This transformation is particularly significant in paediatric surgery, where the stakes are impossibly high and the emotional weight of caring for children creates unique pressures on our teams.
PSIRF is built on four core principles that reshape how we respond to patient safety incidents:
Compassionate engagement and involvement of those affected by patient safety incidents – recognising that patients, families, and staff all need support and must be meaningfully involved in understanding what happened and why.
Application of a range of system-based approaches to learning from patient safety incidents – moving beyond individual blame to understand the complex system factors that contribute to incidents.
Considered and proportionate responses to patient safety incidents – matching our response to the learning potential rather than just the severity of harm.
Supportive oversight focused on strengthening response system functioning and improvement – creating systems that help organisations learn and improve rather than simply comply.
These principles represent more than policy change; they embody a fundamental shift towards psychological safety, systems thinking, and genuine learning from patient safety incidents.
Transition to PSIRF
When NHS England asked organisations to transition to PSIRF by September 2022, they were required to use their intelligence about what causes patients the most harm in their organisation, focusing these insights as priorities for learning and improvement over the next 2-4 years. This data-driven approach means each organisation has identified different priorities based on their unique risk profile, incident patterns, and local challenges. These priorities are published as part of a Patient Safety Incident Response Plan, and should be available on the Trust’s public facing website.
So what does this mean for paediatric surgery?
I looked at plans from Alder Hey, Sheffield Children's, University Hospitals Bristol and Weston, Great Ormond Street Hospital, Royal Manchester Children's Hospital, and Guy's and St Thomas's.
Universal Priority: Medication Safety. The most striking finding is that medication safety appears as a priority across virtually every organisation we examined. In some this was focussed on TPN and omission/delay of critical medications, in others this was less specific.
Communication failures emerge as another universal theme. Transfer of care and discharge processes appear consistently, and lastly, a few organisations identify deteriorating patient recognition as a priority (this is the most common priority for general acute hospitals).
The Curious Absence of Surgical-Specific Priorities
Perhaps the most striking observation from this analysis is what's not included: across most of these organisations, there is limited focus specifically on surgery and the specific challenges around paediatric surgery.
Guy's and St Thomas's provides a notable exception, identifying "surgical errors as a result of not using the surgical checklist" representing the only explicitly surgical priority we found across this sample of major paediatric surgery centres, although this priority isn’t linked specifically to paediatric surgery.
The Data Question: Is Surgery Invisible?
This absence raises critical questions: Is it because your data is not there? When we examine the incident and organisational data that these priorities emerge from, we cannot see substantial evidence of paediatric surgery-specific issues being captured and analysed.
This could reflect several possibilities:
Under-reporting in surgical settings: Are surgical teams reporting incidents at the same rate as other clinical areas?
Classification challenges: Are surgical incidents being categorised in ways that make them invisible in organisational data analysis? An intraoperative complication might be recorded as a "medication incident" or "equipment failure" rather than a surgical issue. Are delayed follow-ups being lost in big non-specific priorities around admission, transfer and discharge?
Normalisation of surgical risks: Are there surgical complications which may have been made more likely than normal as a result of our (degraded) systems, but rather than being seen as learning opportunities these are being accepted as "inevitable risks"?
Data capture limitations: Do our incident reporting systems adequately capture the complexity of surgical care, or are they better designed for medical ward-based incidents?
What This Means for Paediatric Surgery
The absence of surgery-specific priorities in PSIRF plans doesn't mean there is nothing left to learn in paediatric surgery – it may mean we're not learning from surgical incidents as effectively as we could be. This represents both a challenge and an opportunity for the paediatric surgery community. It may also reflect the length of time the patients spend in theatre vs on a ward, and so scrutiny of your data is needed for you to make that decision!
The Opportunity: PSIRF's emphasis on local intelligence means surgical teams can actively contribute to identifying priorities. By improving incident reporting, analysis, and classification of surgical events, we can ensure surgery gets the attention it deserves in organisational learning systems.
Moving Forward: Making Surgery Visible
As we continue this PSIRF journey, the paediatric surgery community has an opportunity – indeed a responsibility – to ensure surgical safety receives appropriate focus:
Enhance surgical incident reporting: Create cultures where surgical teams feel safe to report incidents, near-misses and recognised complications where they’ve been made more likely by system failures without fear of blame. Work with patient safety teams to ensure surgical incidents are categorised in ways that make them visible in organisational analysis
Get involved in ongoing learning responses: Even if paediatric surgery isn’t the focus of the incident being examined, when learning takes a systems lens it will allow you to input your specific paediatric surgery focus into the learning, which will enable the actions to be developed with paediatric surgery in mind. Is your organisation set up to enable surgeons to attend learning responses? And if not, is there a route to change this?
Conduct your own learning responses: the learning from examining a set of cases from a systems perspective is almost always significant and useful, in the absence of incidents, you could conduct a learning response around an aspect of care you’d like to get some new perspectives on.
Saying sorry is not an admission of guilt: Alongside system based learning responses, PSIRF emphasises the importance of compassionately engaging with patients and/or their families early. Paediatric surgery is often wrought with emotion, and a bespoke approach to supporting patients and their families through the learning process should reflect the unique challenges of paediatric care.
Get paediatric surgery a seat at the table: Use your detailed understanding of surgical risks to propose priorities that reflect the unique challenges of paediatric surgery. Participate actively in your organisation's patient safety incident response planning to ensure surgical perspectives are heard.
Conclusion: The Path Ahead
PSIRF represents our best opportunity yet to create genuinely safer healthcare systems. Its focus on learning, compassion, and systems thinking aligns perfectly with what human factors science has taught us about safety in complex, high-risk environments like paediatric surgery.
But for PSIRF to reach its full potential in surgical settings, we need surgical voices in the conversation. The safety of the children we operate on depends not just on our technical skills, but on our ability to create systems that support excellent care and learn from our inevitable human limitations. If our trust improvement efforts, oversight and ultimately funding are linked to our PSIRF priorities, the absence of surgical priorities is a missed opportunity.
In reflecting on the opportunity of World Patient Safety Day, can we commit to making paediatric surgery visible in our organisational learning systems. Our patients, their families and our own clinical teams deserve nothing less.
Written by Lauren Morgan, Director of Morgan Human Systems Ltd