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

2. GP Curriculum Statement 3.1 Clinical Governance
Statement 3.2 Patient Safety

3. 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)

4. 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.’

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

6. 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

7. Person Approach
It shouldn’t feel like this

8. 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

9. 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.

10. 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

11. Risk Profiling – is it worth looking at?

12. 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

13. 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.

14. 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.

15. 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?

16. 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

17. 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

18. 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

19. 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

20. 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?

21. 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?

22. 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;

23. 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.

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

25. 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)

26. 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.

27. 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

28. 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?

29. 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)

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