GP mythbuster 3: Significant event analysis (SEA)

Significant event analysis can be used to show quality improvement in the 'safety' key question of our GP inspections.

SEA uses case analysis to encourage the whole healthcare team involved in a case or incident to have a supportive discussion. The aim is to use this as a process to allow reflection and learning from the incident and so improve care.

Examples of significant events can be very wide-ranging and can reflect good as well as poor practice. Examples could include:

• new cancer diagnoses.
• coping with a staffing crisis.
• complaints or compliments received by the practice.
• breaches of confidentiality.
• a sudden unexpected death or hospitalisation.
• an unsent referral letter.
• prescribing error.

Aims of SEA

SEA should act as a learning process for the whole practice. Individual SEAs can be shared between members of staff, including GPs, and should focus on disseminating learning within the practice.

The aims of undertaking SEAs are to:

• identify events in individual cases that have been critical (beneficial or detrimental to the outcome) and to improve the quality of patient care from the lessons learnt.
• instigate a culture of openness and reflective learning, not individual blame or self-criticism
• enable team-building and support following stressful episodes
• enable identification of good as well as suboptimal practice
• be a useful tool for team and individual continuing professional development, identifying group and individual learning needs
• share learning between teams within the NHS where adverse events occur at the 'overlap' or in shared domains of clinical responsibility (such as out-of-hours, discharge problems).

SEA and CQC inspections

We want to see evidence of learning from incidents and improving quality. On inspection we look for the impact and learning that has resulted from the SEA. We expect 'good' practices to ensure that the learning from SEAs involves the whole team and becomes embedded in everyday practice.

We would consider this under key line of enquiry (KLOE) S2: Are lessons learned and improvements made when things go wrong?

On our inspections, we will want to see evidence of the following:

1. All staff should be aware of and be able to prioritise a significant event.
2. There should be evidence of information gathering, including factual information on the event such as personal testimonies, written records and other health care documentation. For more complex events, more in-depth analysis will be required.
3. A facilitated team-based meeting should have occurred to discuss, investigate and analyse events. There should be evidence of regular meetings for the purpose of SEAs.

• Analysis of the significant event including:
• what happened and why?
• how could things have been different?
• what can we learn from what happened?
• is change required, if so, what needs to change?

4. Agree, implement and monitor change. There are no fixed end-points; outcomes should be revisited and the implementation and success of any agreed changes monitored at pre-set intervals.
5. Written records and all the processes of the SEAs should be written up to form a report. This should record how effectively the event was analysed.
6. Report, share, review - the SEA should be shared with all members involved in the significant event.