Learning from Significant Events Neil Houston

Helps practices answer the following questions: What happened and why? What can we learn from what happened? What needs to change? How can we stop it happening again ? Or ensure it happens again

Definition of a significant event Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice. The importance of “near misses”

What is Significant Event Commonly a negative experience for patients, relatives, clinicians and others. We can learn as much from good practice as from bad practice. How do you/could you identify events that you can learn from ?

Safety 1 and safety 2 Safety 1 Preventing things going wrong Analysing errors Analysing adverse events Humans as hazards Safety 2 Looking at why things go right Work arounds – humans as rescuers Work as imagined and work as done How do people mitigate against the system Near misses Helps refine the system

Diagnoses Events New diagnoses of cancer, Ischaemic Heart Disease (IHD) or stroke (for prevention, acute care and follow-up) Unplanned pregnancies (for contraceptive advice) Meningitis, measles, mumps, rubella, pertussis, bacteria gastro-enteritis (for prevention) Unexpected deaths Acute asthma, epileptic fits and parasuicide (for prior care) Palliative and terminal care

Prescribing errors Communication Investigations and results Wrong drug prescribed Wrong drug dose Drug interaction Inadequate drug monitoring   Appointment letter sent to wrong address Wrong information given over telephone Important message not acted on Misinterpretation of a handwritten prescription Urgent referral not done Result mis‑filed Result not acted on Investigation request not sent

How do you currently learn from adverse events What process do you use currently? Who is involved ? What are the successes and challenges of your current process ?

The seven stages of Significant Event Analysis Stage 1 – Awareness and prioritisation of a significant event Staff should be confident in their ability to identify and prioritise a significant event when it happens How might you identify a significant event ? Stage 2 – Information gathering Collect and collate as much factual information on the event as possible from personal testimonies, written records and other healthcare documentation.

Stage 3 – The facilitated team-based meeting Appoint a facilitator who will structure the meeting, maintain basic ground rules and help with the analysis of each event. Should be held in a fair, open, honest and non-threatening atmosphere. Agree any ground rules before the meeting starts to reinforce the educational spirit of the SEA and ensure opinions are respected and individuals are not 'blamed'. Follow the structure

Stage 4 – Analysis of the significant event The analysis of a significant event can be guided by answering four questions: What happened? Why did it happen? What has been learned? What needs to be changed or actioned?

What Happened What actually happened Timeline – go back to the start Where Who was involved What was the impact on patients carer staff others

Why did it happen Main and underlying reasons Positive and negative Actions of staff System issues Patient issues The 5 Whys?

Stage 4 – Analysis of the significant event The analysis of a significant event can be guided by answering four questions: What happened? Why did it happen? What has been learned? Or needs to be learnt ? What needs to be changed or actioned?

Stage 5 – Agree, implement and monitor change Any agreed action should be implemented Change should always be monitored by placing it on the agenda for future team or significant event meetings. 'What is the chance of this event happening again?‘ Stage 6 – Write it up Keep a comprehensive, anonymised, written record of every SEA Send to all staff Review the actions

Possible Outcomes No action required Celebration of excellent care Learning need identified and addressed An audit Immediate action Further investigation

Stage 7 – Report, share and review Practices should/might share knowledge of important significant events with others PHO etc so that others may learn from these. Common Problem Interface issues

Have a look at the example Comments / Questions What are Opportunities / Challenges of using this approach

Top Tips Encourage all staff to identify SEAs Remember the excellent care Timing of meetings Who should be at them ? Facilitation Ground rules Focus on the Why System learning Action and Review

Expectations Test ways to improve the way of identifying events to learn from Carry out an SEA meeting using the format presented Submit summary of the report Ask for help / facilitation Guide on the website Questions