Summary: Significant events must be reported correctly, so they can be investigated, and used to change processes to avoid issues in the future.
Intended Users: All Staff
What is a Significant Event and why do we investigate them?
Significant Events are unintended events which could have, or did, lead to harm for one (or more) of our patients. Investigation is vital to understand how to avoid the event in the future. Examples of events include (not exhaustive list):
- Delayed or missed diagnosis
- Medication errors
- Communication errors
- Coping with a staffing crisis
- Complaints or compliments received by the practice
- Breaches of confidentiality
- Unexpected deaths
All staff have a responsibility to identify and report Significant Events to promote learning and improvement within the practice
To report a Significant Event - use our form here. A senior clinician will review the form within a week.
Significant Event Reporting
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Investigations
Significant event analysis (SEA) is defined as occurring when:
"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.”
- Investigation is qualitative and requires a dissection of events, surrounding:
- What happened and why?
- How could things have been different?
- What can we learn from what happened?
- What needs to change?
- There are a wide variety of outcomes, and implementation of fixes will vary with each situation. However, learning will be shared by either speaking directly to the team involved, during PLTs, or sharing with the wider company.
Why do we complete significant event analysis?
- To identify events that led to, and caused the issues (beneficial or detrimental to the outcome) and to improve the quality of patient care from the lessons learnt.
- To instigate a culture of openness, learning not to blame, and reflective learning.
- To enable team building and support following stressful episodes.
- To enable identification of good practice, as well as suboptimal.
- To be a useful tool for team and individual continuing professional development, identifying group and individual learning needs.
- To share SEA between teams within the NHS where adverse events occur at the 'overlap' or in shared domains of clinical responsibility - e.g., out-of-hours (OOH), discharge problems.
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