1. General Practitioner and General Practice Trainer
Knitwear in Southern Russia: Facilitating Learners with Significant Event Analyses
Dr. Shahid Dadabhoy
General Practitioner and General Practice Trainer
The Microfaculty, Chingford Mount Road, Chingford, London E4 8LT

2. Programme
1300. Intro
1310 A submission from one of my appraisees -small group work (discussion)
1330 Calibration from the case
1340 Consensus/discussion on what should be looking for in a log SEA entry
1400 Knitwear in Southern Russia (a fictionalised real case)
1420 Discussion and "washup“
1430 End

3. So what is Significant Event Analysis?
“A process in which individual episodes (when there has been a significant occurrence either
beneficial or deleterious) are analysed in a systematic and detailed way to ascertain what
can be learnt about the overall quality of care, and to indicate any changes that might lead
to future improvements.”
NHS National Patient Safety Agency. Significant Event Audit: guidance for primary care teams (2008)

4. Case 1
Task 13:10-Have a look at this submission in your groups and discuss. Record the key points from your discussion. 13:30-Feedback your discussion to the workshop.

5. 13:40 So what is good SEA evidence anyway?

6. The RCGP Line on SEAs?

7. The Seven Stages of Significant Event Audits
Stage 1 – Awareness and prioritisation of a significant event
Stage 2 – Information gathering
Stage 3 – The facilitated team-based meeting
Stage 4 – Analysis of the SEA
Stage 5 – Agree, implement and monitor change
Stage 6 – Write it up
Stage 7 – Report, share and review

8. 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.
The practice should be fully committed to the routine and regular audit of significant events.

9. 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.
For more complex events, an in-depth analysis will be required to fully understand causal factors.

10. Stage 3 – The facilitated team-based meeting
The team should appoint a facilitator who will structure the meeting, maintain basic ground rules and help with the analysis of each event. The team should meet regularly to discuss, investigate and analyse events.
These meetings are often the key function in co-ordinating the SEA process and they 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’.
Minutes of the meeting should be taken and action points noted. These should be sent to all staff, including those unable to attend the meeting.
An effective SEA should involve detailed discussion of each event, demonstration of insightful analysis,the identification of learning needs and agreement on any action to be taken.

11. Stage 4 – Analysis of the significant event
The analysis of a significant event can be guided by answering four questions:
1. What happened?
2. Why did it happen?
3. What has been learned?
4. What has been changed or actioned?
The possible outcomes may include:
• no action required;
• a celebration of excellent care;
• identification of a learning need;
• a conventional audit is required;
• immediate action is required;
• a further investigation is needed;
• sharing the learning.

12. Stage 5 – Agree, implement and monitor change
Any agreed action should be implemented by staff designated to co-ordinate and monitor change in the same way the practice would act on the results of ‘traditional’ audits.
Progress with the implementation of necessary change should always be monitored by placing it on the agenda for future team or significant event meetings.
Where appropriate, the effective implementation and review of change is vital to the SEA process. To test how well the SEA process has gone, practices should ask themselves ‘What is the chance of this event happening again?’.

13. Stage 6 – Write it up
It is important to keep a comprehensive, anonymised, written record of every SEA, as external bodies will require evidence that the SEA was undertaken to a satisfactory standard. The SEA report is a written record of how effectively the significant event was analysed.

14. Stage 7 – Report, share and review
Reporting when things go wrong is essential in general practice. The practice should formally report (either to the National Reporting and Learning Service, or via the primary care trust/healthcare organisation) those events where patient safety has, or could have been, compromised.

15. 14:00-Case 2
Maladministration of Vaccines The task -Read through the description of the event -What issues can you identify as a group? -Record the key points of your discussion -Feedback to the Group

16. Enhanced Significant Event Analysis – A Human Factors Approach
Paul Bowie, Elaine McNaughton & David Bruce
NHS Education for Scotland
SEAs
perceived as a negative process
“second victim syndrome”
reluctance to acknowledge SEAs
selective to “safe issues”
poor direction to analyses

17. “Human Factors Approach”
People factors (e.g. a newly trained health visitor practising in an immunisation clinic under clinical supervision, while being frequently distracted by parents and colleagues)
Activity factors (e.g. performing repetitive but different vaccination tasks in a very busy and recently combined immunisation clinic, with similarly labelled vaccinations within immediate reach),
Environment factors (e.g. a poorly designed workspace layout and immunisation system, and a well-intentioned practice decision to combine clinics to improve efficiency)

18. Paul Bowie, Elaine McNaughton & David Bruce The Human Factors Model

19. The Rashomon Effect

20. Knitwear in Southern Russia? What is he on about?

21. "C'est magnifique, mais ce n'est pas la médecine. “ "C'est de la folie

22. Dramatis Personae
FitzRoy Somerset, 1st Baron Raglan (CinC British Army)
Dr R
George Bingham, 3rd Earl of Lucan (Cmdr British Cavalry)
Dr L
Brigadier-Gen Colin Campbell
(Cmdr Highland Brigade)
SRN C
James Brudenell, 7th Earl of Cardigan (Cmdr Light Brigade)
Dr C
General Sir James Yorke Scarlett
(Cmdr the Heavy Brigade)
Dr S
Captain Louis Nolan
Dr N

23. The Battle of Balaklava 25th October 1854

24. Get it right, nobody remembers…get it wrong nobody forgets
Questions ?
You live you learn You love you learn You cry you learn You lose you learn You bleed you learn You scream you learn… From “You Learn” Alanis Morrisette 1996