1. Educational Solutions for Workforce Development Pharmacy Significant Event Analysis Fiona McMillan Lead Pharmacist Educational Development

2. Aim To advise on development of a process for the analysis of Significant Events to promote learning and reflection within your team

3. ‘To err is human, to cover up is unforgivable and to fail to learn is inexcusable’’ Liam Donaldson 2004

4. Background SEA embedded medical model Effective analysis allows reflection and learning within the team Positive and negative events Safe and effective medicines management needs systems to ensure that patient safety is maintained. Sharing practice aids development of good practice.

5. 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

6. Examples of Significant Events Wrong drug prescribed Wrong drug dispensed Patient complaints IT issue leading to error Drug interaction not noted Medication labelled incorrectly Lack of communication within healthcare team Issues with training

7. What is the process for analysis and receiving peer comments? Complete SEA proforma Discuss at peer review + include all involved Update Submit to NES Feedback Share again with peers

8. Questions in SEA form What happened? Give adequate detail to enable reviewers to understand the whole picture Why did it happen? Explain reasons from your analysis What have you learned? Can be a list What have you changed? Will this prevent reoccurrence

19. Benefits of SEA Joint Learning + improved patient care Individual analysis Peer review Recording and discussion with peers Peer reviewers

20. Educational Solutions for Workforce Development Pharmacy What benefits do you see? What are your next steps? How could you integrate this into your practice?