Significant Event Analysis

AKA significant event audit, critical incident analysis, facilitated case discussion

Introduction

• What is it and why should I care?

• Which event should we discuss?

• How do we do an SEA?

• An example

Significant Event Analysis

• "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".

Significant Event Analysis

• Not healthcare specific• ‘The Critical Incident Technique’ JC Flanagan

1954• Predecessors – Grand round, M&M etc• ‘Significant event auditing. A study of the

feasibility and potential of case-based auditing in primary medical care.’ Pringle et al 1995

• ‘A First Class Service’ 1998• SEA included in QOF 2004

Which event should we discuss?

• ‘Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice’ NPSA

• Positive or negative• Examples

– Prescribing error– Delay in referral– Death– Breach of confidentiality– Missed/delayed diagnosis

How do we do an SEA?

• Stage 1 – Awareness and prioritisation of a significant event

• Stage 2 – Information gathering• Stage 3 – The facilitated team-based meeting • Stage 4 – Analysis of the significant event• Stage 5 – Agree, implement and monitor change• Stage 6 – Write it up• Stage 7 – Report, share and review

Stage 4 – Analysis of the significant event

1. What happened?

2. Why did it happen?• Preventable factors

3. What has been learnt?

4. What has been changed or actioned?

Example outcomes

• No action required

• A celebration of excellent care

• Identification of a learning need

• A conventional audit is required

• Immediate action is required

• A further investigation is needed

• Sharing the learning

An example

1. What happened?• Mrs A, receptionist at the practice, felt that she

had a UTI and was in too much pain to concentrate at work. She approached one her GP colleagues for advice as she didn’t want to take time off work to see her own GP. She was given a course of amoxicillin and advised to take painkillers. She developed a rash and on further enquiry had forgotten to mention that she was allergic to penicillin.

An example1. What happened?

2. Why did it happen?• No access to patient notes• Patient forgot to mention allergy• Not seeing usual GP

An example1. What happened?

2. Why did it happen?

3. What has been learnt?• Importance of confirming allergy status• Importance of separating colleague and

doctor/patient relationships• Dangers of casual prescribing

An example1. What happened?

2. Why did it happen?

3. What has been learnt?

4. What has been changed or actioned? • New practice policy that all patients must

see their own GP if unwell

References

• http://www.patient.co.uk/doctor/significant-event-audit

• NHS NPSA ‘Significant Event Audit: Guidance for primary care’