1. Educational Solutions for Workforce Development Pharmacy Significant Event Analysis Fiona McMillan Lead Pharmacist Educational Development April 2014

2. Aim To provide information about the analysis of a Significant Event (SE)

3. ‘To err is human, to cover up is unforgivable and to fail to learn is inexcusable’’ Liam Donaldson 2004

4. Background SEA embedded medical model Effective analysis allows reflection and learning within the team Positive and negative events Safe and effective medicines management needs systems to ensure that patient safety is maintained. Sharing practice aids development of good practice.

5. Educational Solutions for Workforce Development Pharmacy What is a Significant Event? “Any event thought by anyone in the health care team to be significant in the care of patients or the conduct of the practice or organisation.’ Pringle et al, 1995

6. Examples of Significant Events Wrong drug prescribed Wrong drug dispensed Patient complaints IT issue leading to error Drug interaction not noted Medication labelled incorrectly Lack of communication within healthcare team Issues with training

7. What is the process for analysis and receiving peer comments? Complete SEA proforma Discuss at peer review + include all involved Update Submit to NES Feedback Share again with peers

8. The Seven Stages of Significant Event Analysis Stage 1: Awareness and prioritisation of a significant event Significant events should be prioritised for analysis based on their consequences (actual or potential) for the quality and safety of patient care. Stage 2: Information gathering Collect information before the SEA meeting using both documentation sources (PMR, SOPs, protocols etc) and from personal accounts (patients, relatives, healthcare staff and individuals from other agencies).

9. Stage 3: The facilitated healthcare team-based meeting It is important to invite all relevant staff to the meeting. Learning needs have to be identified and the meeting should be conducted in an open, fair, honest and non-threatening atmosphere. Stage 4: Analysis of the Significant Event The Four What's: What happened? Why did it happen? What has been learned? What has been changed or actioned?

10. Stage 5: Agree, implement and monitor change This is vital to the success of the analysis of the Significant Event. Stage 6: Write it up Written records should be kept using the NES Significant Event Analysis documentation: http://www.nes.scot.nhs.uk/education-and- training/by-discipline/pharmacy/pharmacists/cpd-audit-sea/significant- event-analysis-for-pharmacy-staff.aspxhttp://www.nes.scot.nhs.uk/education-and- training/by-discipline/pharmacy/pharmacists/cpd-audit-sea/significant- event-analysis-for-pharmacy-staff.aspx Stage 7: Report, share and review......

11. Stage 4 Questions in SEA form What happened? Give adequate detail to enable reviewers to understand the whole picture. Why did it happen? Explain reasons from your analysis by establishing the underlying reasons. What have you learned? Outline the learning needs identified and show that reflection and learning has taken place. What have you changed? Will this prevent reoccurrence?

12. Example of a SEA Form and Peer Feedback NES will make your details anonymous before sending it to be peer reviewed

13. The possible consequences for the patient were well described but does not mention the possible impact the event will have on the staff Described what actually happened... Set the scene.... Who was involved? In your view why did it happen?

14. Usually there is a range of errors or shortcomings which causes the single event so they should all be identified and addressed

15. It is vital that all patient and staff details are omitted in this form Described your learning....involve other members of the team.... in the discussions...

16. What actions have you taken as a result of analysing the event?

17. The feedback is sent back to the submitter as a letter via email.

22. Benefits of SEA Peer reviewers Peer review Recording and discussion with peers Individual analysis Joint Learning + improved patient care

23. Why is SEA important? Analysis will help to reduce manage and reduce risks. Reflection allows time to reflect on the event and understand the reasons why it occurred. Reflection also fulfils some of the CPD requirements. Identifies your own learning needs as well as those in the healthcare team.