Significant Event Analysis

Ramesh MehayApril 2012

(with slides adapted from original work by Dr. Louise Riley)

GP Curriculum

Statement 3.1 Clinical Governance

Statement 3.2 Patient Safety

Definition SEA

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 (Pringle, 1995)

Clinical Governance

‘A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.’

Culture

• Airline industry experience– Learning from events-Root cause analysis– Multidisciplinary and open – No blame culture

To Err is Human

1. Person approach

2. System approach

Person Approach

Systems: Swiss Cheese Model

What the Swiss Cheese Model Tells Us

• Based on the assumption that though we cannot change the human condition we can change the conditions under which humans work.

• When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.

• Reporting culture is essential to fill in the holes.• No blame is an integral part of this.

In General Practice

SEA is becoming more established as a core activity that we all should be doing:•Practices encouraged to have SEA meetings•GPs need to include SEA for appraisal AND it is a mandatory part of evidence for revalidation•Trainees in Y&H must include SEA as NOE

Risk Profiling – is it worth looking at?

Risk Profiling

After defining what can go wrong, there are only 2 other questions you need for risk profiling:1.How bad would that be?2.How likely is it?

(i) Significant Impact and High Likelihood - High Risk (ii) Significant Impact and Low Likelihood - Medium-High Risk (iii) Insignificant Impact and High Likelihood - Medium-Low Risk (iv) Insignificant Impact and Low Likelihood - Low Risk

If it is ‘risky’- back to the definition

1. An individual case in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient)

2. is analysed in a systematic and detailed way 3. to ascertain what can be learnt about the overall quality of

care 4. and to indicate changes that might lead to future

improvements.

An SEA from your experience• Think about a recent significant event.• It doesn’t need to be anything that was formally looked at

through the eyes of Signifcant Event Analysis.• Write about it as if it was a log entry.

An SEA from your experience

Discussion•Think about what happened - who was involved?•What feelings might they have had about the incident?•What about the relationships between the people involved?•Did you write about organisational systems were relevant to the incident?•Did you write about changes to reduce the risk of recurrence?•Barriers to reporting: If you didn’t report it, why?

Who?

• Person/people responsible for the event• Person/people who witnessed it• Person/people who reported it• Person/people who didn’t report it (although they knew or

had an idea it had happened)• Person/people responsible for the team• Person/people affected by the event• Friends and relatives of person/people affected by the event

Feelings & Relationships• Feelings – alarmed, sorry, guilty, angry, desperate, resentful,

confused, indifferent, betrayed, embarrassed, upset, ambivalent, frightened, anxious, victimised, worried, unsupported, worthless, overlooked, belittled, misunderstood, self righteous, shocked, overwhelmed, sad, outraged, indignant, disappointed, despairing, bereft, irritated, impatient, weary, miserable, phlegmatic, discouraged, proud, satisfied, elated, relieved, flattered, glowing, affirmed, vindicated, energised, encouraged, excited, optimistic

• Relationships - co-operative, competitive, collaborative, comradely, equal, unequal, hierarchical, respectful, contemptuous, trusting, mistrustful, bullying, obsequious, dismissive, familiar, unfamiliar, relaxed, tense, formal, informal, supportive, unsupportive, challenging, undermining

Can we make sense of all of this?

• Standard questions– How could things have been different?– What can we learn from what happened?– What needs to change?

• But it’s unlikely that we will learn anything if we don’t take account of people’s feelings, because the feelings get in the way of the learning. This is also true of the relationships between the people involved. Feelings may need to be explored on 1:1 basis before and/or after any SEA meeting

• SEA meeting chair needs group facilitation skills

Systems• Personal organisation (to-do lists, notebooks, electronic reminders etc)• Communication

– Spoken: doctor-patient, within team, handover– Written: medical records (paper, electronic), notice boards, correspondence,

patient messages– Postal systems, telephone systems, electronic systems– Meetings

• Access– Appointment systems– Telephone lines

• Guidelines – Clinical– Procedural

• Training– Induction– Refresher training– Cascading new information to team

RCGP proforma

Now use this structure and do it again•What happened?•Why did it happen?•Who was involved in the discussion of the event?•What have you learned?•What have you changed in the practice as a result of the review?•What have you changed in your personal practice as a result of the review?

DAD

• Gather Data

• Analyse that data

• Decide on a plan – what’s the next step?

Data Gathering – what happened?

• Good data gathering to avoid premature conclusions. Hold a team meeting

• Set the climate – may need to aire feelings to neutralise them, importance of no blame culture. Keep focus on making things better, not apportioning blame.

1. Review care and immediate problems (both positive aspects and aspects needing improvement); Explore knowledge skills & attitudes

2. Timeline of events – needs to include all team members;

Analysis – trying to make sense of it

• Root cause analysis• Relevant scientific papers or articles may be obtained to

inform discussion• Review of possibilities for prevention – think in terms of

KNOWLEDGE, SKILLS, ATTITUDES as well as systems• Consider:– interface issues– team issues– Review possibilities and implications for other

stakeholders like family, community, staff etc.

Decide – what next?

• Plan of action • Summarise & Document• Check everyone is okay• Set a date and method for review/follow up

Outcomes

• Celebration if the care is good• No action if the event could not be prevented• A conventional audit if a deficiency is exposed in a system• Immediate change if a weakness is exposed and a remedy can

be clearly seen

Actions must be specific, measurable, achievable, realistic and time-bound (SMART)

Pitfalls

• ‘Being more aware’ is not good enough!• Actions should be physical actions (something needs to be

physically done) – otherwise it won’t happen.• Need to get everyone on board – otherwise it becomes your

hobby horse and quality of care remains unchanged.

Top Tips 1

• Write a SUBJECTIVE first person (I) narrative of a SEA from the point of view of anyone involved in it except yourself

• Include– What happened (as they see it)– Their relationships with other people involved– Their feelings about the incident

Top Tips 2

• Make an OBJECTIVE note of exactly what happened• And what happened next• And the outcome • And – can you identify any ‘nodal points’ when a key decision

was made which determined what happened next?

Back to RCGP proforma

Re-write your SEA in terms of:•What happened? (Do a time line?)•Why did it happen? (Root cause analysis)•Who was involved in the discussion of the event?•What have you learned? (Analyse)•What have you changed in the practice as a result of the review? (Decide)•What have you changed in your personal practice as a result of the review? (Follow up/Review)

Closing Remarks

• Critical Incident Review key part of GP Practice• Useful learning tool• System based approach• Emphasis on learning from mistakes