GP Significant Event Analysis Tutorials

1. GP Significant Event Analysis Tutorials GERAINT LEWIS-PRIMARY CARE RISK ADVISER Significant Event Analysis

2. Workshop Objectives • By the end of this session you should be able to: • Identify what is a Significant Event? • Undertake a Significant Event Analysis? • Identify the necessary elements needed for a successful SEA meeting • Write up a Significant Event Analysis report

3. What is a significant event?

4. 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

5. NPSA definition “Any event or circumstance that could have lead to un-intended or unexpected harm, loss or damage”

6. 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.

7. SEA in simple terms • is about learning from what has happened and sharing it • analyses events from start to finish • is an inter-professional team activity • identifies problems • shows differences in which different people manage the same situation • is a regular meeting to discuss events ( N.B- Both good and bad) • focuses on system improvement • celebrates success

8. Terminology • Significant Event • Critical Incident-A critical incident is any event or circumstance that caused or could have caused (referred to as a near miss) unplanned harm, suffering, loss or damage. • Adverse event-The NPSA calls adverse events "patient safety incidents" AND • Near miss- near misses "prevented patient safety incidents” • Unusual/unexpected event

9. Time out • What examples can you give of ‘good’ and ‘bad’ Significant Event Analysis in your place of work?

10. 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

11. SEA early evidence on effectiveness • Leads to change rapidly • Built in to the fabric of the organisation • Systematic approach • Encourages a user/patient focus • Includes successes as well as problems N.B. You collect more events if you emphasise effective incidents Flanagan.J. 1953

12. The Philosophy • Change is an emotional process • Supportive • Structured, rigorous • Not blame seeking but quality orientated

13. A guide to SEA-some practicalities….. • How often should you hold SEA meetings ? • Should it be an agenda item within a wider team meeting or be distinct? • How soon after the event has occurred? • How much investigation should you undertake before the meeting? • Who do you involve? • Each practitioner/member of staff will have their own ideas. Allow everyone to contribute and respect their views

14. Some more practicalities Events should be chosen because they: • Are thought important in the life of the practice • May offer some insight into the care the practice provides • REMEMBER SEA DOES NOT SEEK TO ALLOCATE BLAME!

15. Group session 3 What do you think are the benefits of Significant Event Analysis?

16. The benefits of Significant Event Analysis • Improve quality of Practice • Shared learning • Improve teamworking and communication – immediate benefits • Requires only a small amount of preparation • Reduces the likelihood of complaints and the impact of litigation • Moulded by the Practice team to suit your needs

17. Risks of SEA • Unsettling to staff as individuals or collectively • Demoralising • Victimisation • Frustration

18. Four components to be analysed • Adescription 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

19. How do you do significant event analysis ?

20. Step 1- Recording the event • Agreed accessible reporting mechanism • Standard form • Think significant is significant • Do it now! • The good and the bad

21. Step 2 Preparing for SEA I collecting information • What happened • Who was involved • What lead up to it • What was the consequence

22. Step 2 – Preparing for SEAII Organising the meeting • Collate all information relevant to the incident The report, witness statements, relevant protocols, items of equipment etc • Create agenda, recognising: priority of topics / ?flexibility to add ‘hot topics’ • Ensure the right people are there • Select chair and scribe

23. Step 3-Analysis • Get brief summary of what took place from each individual involved • Questions for clarification • What contributed to the incident occurring – look at root causes • Review existing processes • Review existing safety nets • What actually went wrong

24. Step 3 analysis (ii) • What could have been done differently? • What would need to be in place to encourage a different action/behaviour?

25. Step 4- Agreeing outcomes • CONGRATULATIONS • IMMEDIATE ACTION • FURTHER WORK CALLED FOR - a potential topic for quality Improvement • NO ACTION (‘life’s like that’)-but I feel better for talking

26. Step 5 i– Ensuring the learning • Write it up (Good documentation) • Telling everyone in your organisation (communication) • Getting it done (action plan) • Proving we have done it (review)

27. Action Plans • Objective – what are you trying to achieve (should be measurable)? • What are you actually going to do? • Who is responsible for seeing it is done • When must it be done by? • How will you know you have achieved it? • When will you review it?

28. Step 5 ii-Sharing the learning Tell others !! Practices may be reluctant to share negative events but sharing can prevent other organisations from making the same mistakes.

29. Step 6-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?

30. The report-What do you think should be in it?

34. Group Work 4-Case studies In groups you will now conduct an SEA meeting as you would in general practice following one of the case studies provided. Follow the steps you have learned today to conduct the SEA meeting and remember: • Record your findings • Discuss the event • Agree what happened and how • Agree how it could be avoided in future • Document the meeting • Produce an action plan

35. 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? Yes Yes Yes Is there potential for learning or change? SEA!

36. Summary and conclusion - SEAs ? • WHAT? • Pick incidents which stand out as unusual or unexpected • Learn from actual experience by reviewing events. • WHY? • Learning lessons & sharing the learning • Improving quality • Improving teamworking & communication • Reducing likelihood of complaints & impact of litigation • HOW? • Involvement of entire team • “Low blame.” • SEA forms as a guide