1. Significant Event Analysis
AKA significant event audit, critical incident analysis, facilitated case discussion

2. Introduction What is it and why should I care?
Which event should we discuss?
How do we do an SEA?
An example

3. Significant Event Analysis
"individual cases in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care and to indicate changes that might lead to future improvements".

4. Significant Event Analysis
Not healthcare specific
‘The Critical Incident Technique’ JC Flanagan 1954
Predecessors – Grand round, M&M etc
‘Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care.’ Pringle et al 1995
‘A First Class Service’ 1998
SEA included in QOF 2004
Based on work first published by JC Flanagan, a psychologist who worked with pilots in WW2.
Some form of critical incident analysis has been present in the NHS since inception, e.g. grand rounds, M&M, confidential inquiries
In 1998 the DoH produced ‘A first class service’, a document which introduced the formal concept of clinical governance. Built upon with papers in 2000 (‘CMO: An organisation with Memory’) and 2001 (‘Building a Safer NHS for Patients’) and SEA was pushed as a method for improving patient safety.
In 2004 SEA was included in QOF

6. Which event should we discuss?
‘Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice’ NPSA
Positive or negative
Examples
Prescribing error
Delay in referral
Death
Breach of confidentiality
Missed/delayed diagnosis

7. How do we do an SEA?
Stage 1 – Awareness and prioritisation of a significant event
Stage 2 – Information gathering
Stage 3 – The facilitated team-based meeting
Stage 4 – Analysis of the significant event
Stage 5 – Agree, implement and monitor change
Stage 6 – Write it up
Stage 7 – Report, share and review

8. Stage 4 – Analysis of the significant event
What happened?
Why did it happen?
Preventable factors
What has been learnt?
What has been changed or actioned?

9. Example outcomes No action required A celebration of excellent care
Identification of a learning need
A conventional audit is required
Immediate action is required
A further investigation is needed
Sharing the learning

10. An example What happened?
Mrs A, receptionist at the practice, felt that she had a UTI and was in too much pain to concentrate at work. She approached one her GP colleagues for advice as she didn’t want to take time off work to see her own GP. She was given a course of amoxicillin and advised to take painkillers. She developed a rash and on further enquiry had forgotten to mention that she was allergic to penicillin.

11. An example Why did it happen? No access to patient notes
What happened?
Why did it happen?
No access to patient notes
Patient forgot to mention allergy
Not seeing usual GP

12. An example What has been learnt?
What happened?
Why did it happen?
What has been learnt?
Importance of confirming allergy status
Importance of separating colleague and doctor/patient relationships
Dangers of casual prescribing

13. An example What has been changed or actioned?
What happened?
Why did it happen?
What has been learnt?
What has been changed or actioned?
New practice policy that all patients must see their own GP if unwell

14. References http://www.patient.co.uk/doctor/significant-event-audit
NHS NPSA ‘Significant Event Audit: Guidance for primary care’