Significant Events

Significant Event Analysis (SEA) An SEA is concerned with investigating any

occurrence which are identified by any practice members and are considered to be ‘significant’

It allows the team to highlight and learn from both strengths and weaknesses in the care we provide.

Improving the quality and safety of patient care is a key element in clinical governance within the practice and SEA have an important role in contributing to this aim.

7 Stages of SEA’s

1. Recording the significant event

2. Information gathering

3. Team based meeting

4. Analysis of significant event

5. Agree, implement and monitor change

6. Write it up

7. Report, share and review

Examples of Significant Events Any incident of actual or possible injury to patient Any injury sustained by a member of staff at work Any near miss Medication errors/issues Death on the premises New cancer diagnoses Deaths where terminal care has taken place at home Suicides Mental health act admissions Child protection cases Inaccurate or incomplete medical records

Examples cont’d

Delayed or missed diagnosis Referral difficulties Failure in message handling Events which have resulted in a complaint Health & safety issues or incidents Emergency situations involving patients or members

of the public Underage pregnancy Breaches of confidentiality Equipment or computer failure Fire, theft or vandalism

Objectives of Reporting

To record adverse incidences effecting, or with the potential to effect patients or staff

To record ‘near misses’ so that steps may be taken to prevent a recurrence

To learn from the event as a team, discuss and put change or procedures in place to improve

To commend and acknowledge good practice To provide a permanent record of events and evidence of

remedial steps taken To satisfy the requirements of QOF and nationally required

incident reporting standards To operate and discuss incidents in an open environment and

within the safety of a ‘blame free culture’

1. Recording Significant Events Event should be recorded as soon as possible on

the significant event recording sheet (my network places/shared on EMIS/2010/significant events and complaints)

Any staff member can record the event if they had a significant part in, or witnessed an incident

There can be more than one form filled in for the same event by different staff, this will ensure that each account is as accurate as possible

The date & time, person completing the form, event identifier and details of the event should all be put on the form initially

2. Information Gathering

As much factual information as possible regarding the event should be collated

This can include witness statements, medical records and thoughts and opinions of those directly and indirectly involved in the case

All information should be passed to the practice manager to collate

At this point we can assess whether any urgent or remedial action is required without delay and initiate this

3. Team Based Meeting

The meeting should be conducted in an open, fair, honest and non-threatening atmosphere

Notes of the meeting must be kept and any action points noted and these should be circulated to all staff not just those present at the meeting

Meetings should be held routinely – monthly or quarterly when all events of interest can be highlighted, discussed and analysed with all relevant people present and the opportunity for others to offer their thoughts and suggestions

A facilitator should be appointed, this can be the person with the greatest knowledge of the event or the practice manager

4. Analysis of the Event

There are 4 questions to be answered when analysing a significant event

1. What happened?

2. Why did it happen?

3. What has been learned?

4. What has been changed or actioned?

5. Agree, Implement and Monitor Change Four possible outcomes from significant

event meeting1. Congratulations

2. Immediate action

3. Further work called for

4. No action

6. Write it Up

It is important to keep a comprehensive, anonymised, written record of every SEA as external bodies require evidence that the SEA was undertaken to the required standard.

The SEA should include Date of event and date of the meeting Lead investigator In depth analysis of the event with the four

questions in previous slide answered

7. Report, Share and Review

The completed report should be shared with all the practice team and the HSCB

Seek educational feedback on the review at appraisal, sharing with other managers or at clinical governance meeting

Review how we could have done the SEA better