1. Educational Solutions for Workforce Development Pharmacy Significant Event Analysis Analysis of an event to change practice Val Reilly SEA Reviewer NHS Education for Scotland

2. Educational Solutions for Workforce Development Objectives for the session Pharmacy What is a Significant Event? What is Significant Event Analysis (SEA)? How do I choose an event to analyse? How does SEA differ from Incident reporting? Examples of SEAs received What does SEA involve? The SEA tool The Peer Review Process How can you integrate this into your practice?

3. 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 ‘ A Significant Event [SE] can be a negative or a positive event that has been important enough to an individual, to make them reflect, analyse and learn from the event. In most cases, the Significant Event Analysis [SEA] explores an event with the view to assess the impact on all involved, to act as a trigger for change through reflection and discussion with those who were involved. In analysis of all significant events there should be learning from those involved. A strong analysis will involve as many of those who were involved in the event, in some way, in the discussions as this ‘team approach’ will promote learning at a range of levels. F McMillan 2010

4. Educational Solutions for Workforce Development Pharmacy What is Significant Event Analysis? SEA is a process whereby an event that was significant to an individual practitioner, is analysed by those involved, with a view to encouraging reflection and learning. Reporting and analysing the SEA involves the completion of a proforma for submission that is then reviewed by 2 x trained peer reviewers who have been calibrated. The author receives feedback from their analysis to strengthen their learning. provides an opportunity of using an event significant to the practitioner, as a learning opportunity. provides a tool for improving patient safety and helping manage risks in healthcare. acts as a means of identifying and prioritising an individuals learning needs.

5. Educational Solutions for Workforce Development Pharmacy How do I choose a SE to analyse? A significant event is chosen by the individual which will then submit the analysis Event significant to care of patient, conduct of team, organisation………. doesn’t have to be negative [error] jus something that will promote learning from reflection. Topic can be, behaviours, interpersonal skills, team working, workplace processes as well as learning from clinical cases.

6. How does SEA differ from local Incident reporting? Submitting and SEA may be part of regulation process in future. Research shows that exploring an event using the headings in the proforma, promotes learning. Completing the submission form involves describing the event in detail, those involved, their roles, reasons for the event, options for change and reflections as to why the incident occurred. It is to do with learning….. Peer review process brings other suggestions for further learning and strengthens practitioners CPD.

7. Examples of SEAs… Dispensing process: issue with dispensing of methadone Communication: lack of communication…leading wrong dose being prescribed. IT: issue with data entry..GPASS computer system leading to prescription error Training: trainer not following up actions with trainee….leading to issues with patient care. IV procedures: issue with IV practices on ward…. Medication: wrong insulin dispensed: analysis of procedure Interview: analysis of the interview with reflections for future behaviour and improvement.

8. Educational Solutions for Workforce Development Pharmacy The Benefits of SEA Analysis of an event provides a wider perspective of learning from practice. Provides a tool to formalise team/ peer review in the workplace. External perspectives on incidents adds to learning or reinforces actions already taken. Individual support to learning and closure on incidents/events.

9. What do I do to submit an SEA? Submit to NES via e mail in standard report format from NES website Report is anonymised to 2 trained peer reviewers, who independently review the SEA using a standard template return with feedback Outcome of peer review collated and fedback to individual Individual reflects on points raised for clarification by the peer reviewers

10. Educational Solutions for Workforce Development Pharmacy What does it involve? There are seven simple steps: Identify and prioritise the significant event Collect the facts Arrange a meeting/ conversations to discuss with those involved Undertake a structured analysis of what has happened Agree actions Write it up Peer Review Monitor agreed change

11. Educational Solutions for Workforce Development Pharmacy Provides the framework for the structured analysis under four headings: What happened? Why did it happen? What have you learned? What have you changed? The SEA tool

17. Educational Solutions for Workforce Development Pharmacy The Peer Review Process Trained pharmacists from each Scottish Health Board -Peer Review Network created Includes pharmacists from community, primary care, hospital, academia, education and management …..so not necessarily from your area of work Returned with educational feedback Outcome of peer review & educational feedback collated and sent to submitting individual for their consideration Our focus of feedback is on individual/author, but process of reflection and learning naturally encourages learning of team

18. Educational Solutions for Workforce Development Pharmacy What benefits do you see? What are your next steps? What practical steps can be taken to increase awareness/ encourage participation? Consider-can SEA be Complimentary to existing systems/ meetings/ approaches? Triggered or catalysed by existing processes? Used to formalise existing incident/event review? A regular agenda item? Used to support individual learning and CPD? Used to support team learning? How could you integrate this into your practice?