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Background PSIRF (NHS England. Patient Safety Incident Response Framework [internet]) has been introduced in the NHS in England, to support a shift towards compassionate engagement and system-based learning from clinical incidents, thus promoting a just culture. There are challenges to implementation in small, specialist services.Aims We report on its introduction to a children’s hospice, and its value in investigating higher-than-expected rate of subcutaneous-site reactions.Methods Having launched PSIRF organisationally, we introduced weekly incident response meetings. One of the first themes identified was a spike in unexpected reactions to infusion sites in two children on multi-drug infusions. We discussed actions needed to investigate the issues and mitigation possible.Results Six incident forms relating to the theme were received, leading to the following actions:We made a devices alert to the MHRA, for the specific infusion device.Diluents were substituted and dexamethasone was added to the infusion.Other children’s palliative care services were contacted to share experience, and one had had a similar issue.We contacted the device manufacturer for further advice and to notify them of the batch.We noted the batches of the medications concerned and also split the infusion into two separate pumps.Information gathered will be included in the next version of the shared syringe-driver guidance for the region.Conclusions PSIRF focuses on moving away from a blame culture to one that is compassionate and recognises wider system issues. Here we show an increased level of incident reporting, identification of themes, intelligent discussion around mitigation and causality, wider sharing of learning and a plan to update guidance, due to its introduction. As a smaller organisation, we will share our learning with the system, to maximally benefit from PSIRF. Our PSIRF experience will be shared via Together for Short Lives/Hospice UK, supporting other organisations with this change in practice.