Significant Event Analysis Paul Myres Primary Care Quality Information Service March 2011

What is Significant Event Analysis ? “a process in which individual episodes (cases) 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”. Professor Mike Pringle, 1995

What is a Significant Event ? An event thought by anyone in a clinical team to be significant to the care of patients or the conduct of the practice Usually an event where something has gone wrong, or could have gone wrong Can also be applied where something has gone extremely well and the practice can learn from this to enhance the patient experience.

Terminology Significant Event Critical Incident-A critical incident is any event or circumstance that caused or could have caused unplanned harm, suffering, loss or damage. Adverse event- caused harm an actual "patient safety incident" Near miss- harm did not occur Unusual/unexpected event

Patient Safety Incidents definitions of harm Level of SeverityExplanation No HarmA situation where no harm occurred LowIncident which required extra observation or minor treatment and caused minimal harm ModerateIncident which resulted in further treatment, possible surgical intervention, cancelling of treatment or transfer to another area and which caused short term harm SevereIncident which caused permanent or long term harm DeathIncident which caused death

Some examples: good and bad Drug reactions Theft of prescription pad Wrong notes on home visit Managing flu epidemic Successful flu campaign Successful management of a crisis Under-age pregnancy Coping with staff illness Drug errors Complaints and compliments Breaches of confidentiality

The Benefits of Significant Event Analysis Improved quality and safety of practice Shared learning Improved teamworking and communication – Requires only a small amount of preparation Reduces the likelihood of complaints and the impact of litigation Reassurance

Risks of SEA Unsettling to staff as individuals or collectively Demoralising Victimisation Time stealing

A description of what led to the incident The actions or behaviours of those involved in the incident Pre-existing processes and systems The consequence of the incident Four components to be analysed

Stage 1- Awareness and prioritisation of a significant event Agreed accessible reporting mechanism Standard form Think significant is significant Do it now! The good and the bad

Stage 2 Gathering information What happened Who was involved What lead up to it What was the consequence

Stage 3 – Organising the meeting Collate all information relevant to the incident The report, witness statements, relevant protocols, items of equipment etc Ensure the right people are there Agree Ground Rules - stress formative nature

Stage 4-Analysis Description of what happened (accounts from those involved) Questions for clarification What contributed to the incident occurring – look at root causes  Review existing processes  Review existing safety nets  What actually went wrong

Stage 4 analysis (ii) What could have been done differently? What would need to be in place to encourage a different action/behaviour?

Stage 5 - Agreeing outcomes Immediate action Further work needed No action (‘life’s like that’)-but I feel better for talking Congratulations

Stage 5 Implement and monitor change - Action Plans 1.Objective – what are you trying to achieve (should be measurable)? 2.What are you actually going to do? 3.Who is responsible for seeing it is done 4.When must it be done by? 5.How will you know you have achieved it? 6.When will you review it?

Stage 6 – Ensuring the learning Write it up Tell everyone in the practice Get it done (action plan) Prove we have done it (review)

Stage 7 Report & share Tell others- LHB NPSA (National Reporting & Learning Service)

Stage 7-Review :revisiting previous events All significant events should be reviewed at least annually Are there any themes? Check that actions have been implemented and changes in practice are still being observed Are there more lessons to be learned?

Significant Event Report Date & Time of event Date and time of report Who is reporting it and to whom Who was involved What happened What was the outcome Date received by SEA Manager/CGLEAD Immediate action taken

Significant Event Analysis Meeting Date of event Date of meeting and who present What happened – incl where and who Why or how did it happen Predisposing factors Possible preventing & alleviating factors Actions to be taken Review dat e

Was this a Significant Event? Was the event out of the ordinary? Better or worse than usual? Does anyone in the team feel this should be discussed? Was anyone upset or harmed by the event? Is there potential for learning or change? SEA! Yes