Significant Event Analysis

Paul MyresPrimary Care Quality Information Service

March 2011

What is Significant Event Analysis ?

• “a process in which individual episodes (cases) 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”.

• Professor Mike Pringle, 1995

What is a Significant Event ?

• An event thought by anyone in a clinical team to be significant to the care of patients or the conduct of the practice

• Usually an event where something has gone wrong, or could have gone wrong

• Can also be applied where something has gone extremely well and the practice can learn from this to enhance the patient experience.

Terminology

Significant Event

• Critical Incident-A critical incident is any event or circumstance that caused or could have caused unplanned harm, suffering, loss or damage.

Adverse event- caused harman actual "patient safety incident"

Near miss- harm did not occur • Unusual/unexpected event

Patient Safety Incidents definitions of harm

Level of Severity Explanation

No Harm A situation where no harm occurred

Low Incident which required extra observation or minor treatment and caused minimal harm

Moderate Incident which resulted in further treatment, possible surgical intervention, cancelling of treatment or transfer to another area and which caused short term harm

Severe Incident which caused permanent or long term harm

Death Incident which caused death

Some examples: good and bad

• Drug reactions• Theft of prescription pad • Wrong notes on home visit• Managing flu epidemic • Successful flu campaign• Successful management of a crisis • Under-age pregnancy • Coping with staff illness • Drug errors • Complaints and compliments • Breaches of confidentiality

The Benefits of Significant Event Analysis

• Improved quality and safety of practice• Shared learning• Improved teamworking and communication – • Requires only a small amount of preparation• Reduces the likelihood of complaints and the

impact of litigation• Reassurance

Risks of SEA

• Unsettling to staff as individuals or collectively

• Demoralising• Victimisation• Time stealing

• A description of what led to the incident

• The actions or behaviours of those involved in the incident

• Pre-existing processes and systems• The consequence of the incident

Four components to be analysed

Stage 1- Awareness and prioritisation of a

significant event

• Agreed accessible reporting mechanism• Standard form • Think significant is significant • Do it now!• The good and the bad

Stage 2 Gathering information

• What happened• Who was involved• What lead up to it• What was the consequence

Stage 3 – Organising the meeting

Collate all information relevant to the incident

The report, witness statements, relevant protocols, items of equipment etc

Ensure the right people are thereAgree Ground Rules - stress formative

nature

Stage 4-Analysis• Description of what happened (accounts

from those involved) • Questions for clarification• What contributed to the incident occurring

– look at root causes Review existing processesReview existing safety netsWhat actually went wrong

Stage 4 analysis (ii)

• What could have been done differently?

• What would need to be in place to encourage a different action/behaviour?

Stage 5 - Agreeing outcomes

• Immediate action• Further work needed • No action (‘life’s like that’)-but I

feel better for talking• Congratulations

Stage 5 Implement and monitor change - Action Plans

1. Objective – what are you trying to achieve (should be measurable)?

2. What are you actually going to do?

3. Who is responsible for seeing it is done

4. When must it be done by?

5. How will you know you have achieved it?

6. When will you review it?

Stage 6 – Ensuring the learning

• Write it up • Tell everyone in the practice • Get it done (action plan)• Prove we have done it (review)

Stage 7 Report & share

• Tell others- LHB

NPSA (National Reporting & Learning Service)

Stage 7-Review :revisiting previous events

• All significant events should be reviewed at least annually

• Are there any themes?• Check that actions have been

implemented and changes in practice are still being observed

• Are there more lessons to be learned?

Significant Event Report

• Date & Time of event• Date and time of report• Who is reporting it and to whom• Who was involved• What happened• What was the outcome• Date received by SEA Manager/CGLEAD• Immediate action taken

Significant Event Analysis Meeting

• Date of event• Date of meeting and who present• What happened – incl where and who• Why or how did it happen• Predisposing factors• Possible preventing & alleviating factors• Actions to be taken• Review date

Was this a Significant Event?

Was the event out of the ordinary?

Better or worse than usual?

Does anyone in the team feel this should be

discussed?

Was anyone upset or

harmed by the event?

Is there potential for learning or change?

SEA!

Yes

YesYes