Educational Solutions for Workforce Development

Pharmacy

Significant Event Analysis

Fiona McMillanLead Pharmacist Educational Development

Aim

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

‘To err is human, to cover up is unforgivable and to fail to learn is

inexcusable’’

Liam Donaldson 2004

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.

Educational Solutions for Workforce Development

PharmacyWhat 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 ororganisation.’

Pringle et al, 1995

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

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

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

Benefits of SEA

Peer

reviewers

Peer review

Recording and

discussion with peers

Individual

analysis

Joint

Learning

+

improved patient

care

Educational Solutions for Workforce Development

Pharmacy

•What benefits do you see?

•What are your next steps?

How could you integrate this into your practice?