2Introduction What is it and why should I care? Which event should we discuss?How do we do an SEA?An example
3Significant 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".
4Significant Event Analysis Not healthcare specific‘The Critical Incident Technique’ JC Flanagan 1954Predecessors – 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’ 1998SEA included in QOF 2004Based 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 inquiriesIn 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
6Which 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’ NPSAPositive or negativeExamplesPrescribing errorDelay in referralDeathBreach of confidentialityMissed/delayed diagnosis
7How do we do an SEA?Stage 1 – Awareness and prioritisation of a significant eventStage 2 – Information gatheringStage 3 – The facilitated team-based meetingStage 4 – Analysis of the significant eventStage 5 – Agree, implement and monitor changeStage 6 – Write it upStage 7 – Report, share and review
8Stage 4 – Analysis of the significant event What happened?Why did it happen?Preventable factorsWhat has been learnt?What has been changed or actioned?
9Example outcomes No action required A celebration of excellent care Identification of a learning needA conventional audit is requiredImmediate action is requiredA further investigation is neededSharing the learning
10An 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.
11An example Why did it happen? No access to patient notes What happened?Why did it happen?No access to patient notesPatient forgot to mention allergyNot seeing usual GP
12An example What has been learnt? What happened?Why did it happen?What has been learnt?Importance of confirming allergy statusImportance of separating colleague and doctor/patient relationshipsDangers of casual prescribing
13An 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