Significant Event Analysis Ramesh Mehay (with slides adapted from original work by Dr. Louise Riley, Bradford)

GP Curriculum Statement 3.1 Clinical Governance Statement 3.2 Patient Safety

Definition SEA 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 (Pringle, 1995)

Clinical Governance ‘A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.’

Culture Airline industry experience Learning from events-Root cause analysis Multidisciplinary and open No blame culture

To Err is Human Person approach System approach Person approach focuses on the errors of individuals, blaming them for errors- bad things happen to bad people System approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects Background in aviation and nuclear power industries and air traffic control centres Lets think of the pros and cons of these two approaches

Person Approach It shouldn’t feel like this

Systems: Swiss Cheese Model Advocates the systems approach- there are several layers of safeguards put in place ideally all intact but there are likely to be holes in them as in the swiss cheese Holes in the defences are active and latent Active to do with what happens at the time –unsaf acts committed by those involvedeg someone files a hospital letter without acting on the request for a repeat xray- persons centred approach stops there But there are almost always reasons why Latent- are the methods of communication between the hospital and the system for dealing with them in the practice,time pressures inadequate training

What the Swiss Cheese Model Tells Us Based on the assumption that though we cannot change the human condition we can change the conditions under which humans work. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed. Reporting culture is essential to fill in the holes. No blame is an integral part of this.

In General Practice SEA is becoming more established as a core activity that we all should be doing: Practices encouraged to have SEA meetings GPs need to include SEA for appraisal AND it is a mandatory part of evidence for revalidation Trainees in Y&H must include SEA as NOE

Risk Profiling – is it worth looking at?

Risk Profiling After defining what can go wrong, there are only 2 other questions you need for risk profiling: How bad would that be? How likely is it? (i) Significant Impact and High Likelihood - High Risk (ii) Significant Impact and Low Likelihood - Medium-High Risk (iii) Insignificant Impact and High Likelihood - Medium-Low Risk (iv) Insignificant Impact and Low Likelihood - Low Risk

If it is ‘risky’- back to the definition An individual case in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) is 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.

An SEA from your experience Think about a recent significant event. It doesn’t need to be anything that was formally looked at through the eyes of Signifcant Event Analysis. Write about it as if it was a log entry.

An SEA from your experience Discussion Think about what happened - who was involved? What feelings might they have had about the incident? What about the relationships between the people involved? Did you write about organisational systems were relevant to the incident? Did you write about changes to reduce the risk of recurrence? Barriers to reporting: If you didn’t report it, why?

Who? Person/people responsible for the event Person/people who witnessed it Person/people who reported it Person/people who didn’t report it (although they knew or had an idea it had happened) Person/people responsible for the team Person/people affected by the event Friends and relatives of person/people affected by the event

Feelings & Relationships Feelings – alarmed, sorry, guilty, angry, desperate, resentful, confused, indifferent, betrayed, embarrassed, upset, ambivalent, frightened, anxious, victimised, worried, unsupported, worthless, overlooked, belittled, misunderstood, self righteous, shocked, overwhelmed, sad, outraged, indignant, disappointed, despairing, bereft, irritated, impatient, weary, miserable, phlegmatic, discouraged, proud, satisfied, elated, relieved, flattered, glowing, affirmed, vindicated, energised, encouraged, excited, optimistic Relationships - co-operative, competitive, collaborative, comradely, equal, unequal, hierarchical, respectful, contemptuous, trusting, mistrustful, bullying, obsequious, dismissive, familiar, unfamiliar, relaxed, tense, formal, informal, supportive, unsupportive, challenging, undermining

Can we make sense of all of this? Standard questions How could things have been different? What can we learn from what happened? What needs to change? But it’s unlikely that we will learn anything if we don’t take account of people’s feelings, because the feelings get in the way of the learning. This is also true of the relationships between the people involved. Feelings may need to be explored on 1:1 basis before and/or after any SEA meeting SEA meeting chair needs group facilitation skills

Systems Personal organisation (to-do lists, notebooks, electronic reminders etc) Communication Spoken: doctor-patient, within team, handover Written: medical records (paper, electronic), notice boards, correspondence, patient messages Postal systems, telephone systems, electronic systems Meetings Access Appointment systems Telephone lines Guidelines Clinical Procedural Training Induction Refresher training Cascading new information to team

RCGP proforma Now use this structure and do it again What happened? Why did it happen? Who was involved in the discussion of the event? What have you learned? What have you changed in the practice as a result of the review? What have you changed in your personal practice as a result of the review?

DAD Analyse that data Decide on a plan – what’s the next step? Gather Data Analyse that data Decide on a plan – what’s the next step?

Data Gathering – what happened? Good data gathering to avoid premature conclusions. Hold a team meeting Set the climate – may need to aire feelings to neutralise them, importance of no blame culture. Keep focus on making things better, not apportioning blame. Review care and immediate problems (both positive aspects and aspects needing improvement); Explore knowledge skills & attitudes Timeline of events – needs to include all team members;

Analysis – trying to make sense of it Root cause analysis Relevant scientific papers or articles may be obtained to inform discussion Review of possibilities for prevention – think in terms of KNOWLEDGE, SKILLS, ATTITUDES as well as systems Consider: interface issues team issues Review possibilities and implications for other stakeholders like family, community, staff etc.

Decide – what next? Plan of action Summarise & Document Check everyone is okay Set a date and method for review/follow up

Outcomes Celebration if the care is good No action if the event could not be prevented A conventional audit if a deficiency is exposed in a system Immediate change if a weakness is exposed and a remedy can be clearly seen Actions must be specific, measurable, achievable, realistic and time-bound (SMART)

Pitfalls ‘Being more aware’ is not good enough! Actions should be physical actions (something needs to be physically done) – otherwise it won’t happen. Need to get everyone on board – otherwise it becomes your hobby horse and quality of care remains unchanged.

Top Tips 1 Write a SUBJECTIVE first person (I) narrative of a SEA from the point of view of anyone involved in it except yourself Include What happened (as they see it) Their relationships with other people involved Their feelings about the incident

Top Tips 2 Make an OBJECTIVE note of exactly what happened And what happened next And the outcome And – can you identify any ‘nodal points’ when a key decision was made which determined what happened next?

Back to RCGP proforma Re-write your SEA in terms of: What happened? (Do a time line?) Why did it happen? (Root cause analysis) Who was involved in the discussion of the event? What have you learned? (Analyse) What have you changed in the practice as a result of the review? (Decide) What have you changed in your personal practice as a result of the review? (Follow up/Review)

Closing Remarks Critical Incident Review key part of GP Practice Useful learning tool System based approach Emphasis on learning from mistakes