Significant event analysis
The first part of this section gives examples of how to do an individual significant event analysis where you are the reporting clinician and so this is for information only. This template exists already on the appraisal web site under Revalidation Templates or you may have a practice-based template that you use to inform the LHB. The second part gives a reflective tool that an individual can use to examine their role within the significant event monitoring system of their practice where they are not the reporting clinician.
Significant event analysis if carried out correctly can be a powerful learning tool acting as a catalyst for change. A significant event may be defined as “Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice” (Pringle et al 1995).
Significant events can be an event where something has gone wrong, where a less correct course of action has been taken or may be an example of where the system or an individual has worked well and the event is analysed in an attempt to ensure that the system will perform equally well should the same situation arise again.
Significant events should not be used to apportion blame, rather, to foster an environment of openness and a willingness to examine practice and systems to improve services and safety.
Significant Event Template (also available on appraisal web site)
| Title of event |
|---|
| Child with meningitis |
| Date of event |
| 3/1/14 |
| Date of SEA meeting |
| 9/1/14 |
| Personnel present and role |
| Drs A, B and C, practice manager, senior practice nurse |
| Description of event |
| At 8am on a Monday morning a mother rang the practice and requested a house call for her 8 year old child. The receptionist was alarmed by the symptoms described (headache and light hurting his eyes) and advised the mother to immediately bring the child to surgery. The child arrived 5 minutes later and was brought into my room immediately. A quick assessment showed this child to have meningism, in the meantime the receptionist alerted another doctor in the practice and the practice nurse. Penicillin arrived with the nurse and my partner made arrangements for hospitalisation, the nurse drew up the penicillin and I continued my clinical assessment. |
| What went well? |
|
| What could have been done better? |
| This is a very positive significant event – everything went well. We need to learn from this and ensure up to date resuscitation training for all staff. Of particular note the availability of emergency medication needs examination |
| Reflections on the event (consider Knowledge skills and performance· Safety and quality· Communication partnership and teamwork· Maintaining trust) I was pleased that my clinical skills in spotting a case of meningitis had not degraded since hospital days and that I was able to give the recognised first line treatment at the correct dose (600mg of phenoxymethylpenicillin). The child had definite photophobia, was irritated, had a positive Kernig’s sign and at least one petechiae on the upper left chest, also a CRT of > 2 seconds. I contacted the ward later that day and the child was stable on HDU. |
| What changes have been agreed? (Personal or Team) |
| The practice nurse now has a list of emergency medication expected to be on site and up to date this is checked monthly as per a protocol.. The doctor’s bags are checked and restocked monthly. |
| Changes carried out and their effect |
| The changes have been implemented in full. Monthly audits show that emergency medication is being checked and maintained as per the protocol as are the doctors’ bags. |
Reflective tool regarding significant event monitoring in practice [For use if not directly involved in a significant event]
You may download a template here.
| Describe the significant event policy in your practice – you may wish to include your template in supporting documentation | Significant event reporting is encouraged from all members of the team. We encourage both good and “bad” reporting, we have a template (available in supporting documentation) that allows reporting of the circumstances, identifies the issues and makes the solutions explicit. It is a confidential process but in a small organisation such as ours the personnel involved are easily identifiable – we get around this by fostering a no blame culture and the “there by the grace of God go I” attitude. |
| When are significant events discussed and who is present at the meeting? | They are discussed at our monthly multidisciplinary meeting to which all members of the team are invited. Any event involving a serious issue of patient safety would be discussed immediately by partners present at the end of morning surgery that day or the next day – any action taken would then still be reported to the monthly team meeting |
| Describe an example of your involvement in significant event analysis | I have been fortunate this year not to have been involved in a significant event. I am however an active participant in the process. We had one event this year with a “near miss” – one of our partners prescribed a beta blocker for an asthmatic – fortunately this was picked up by the pharmacist – this was discussed at the team meeting. It was obvious which partner had done this by their reaction. After the meeting I was able to have a personal talk with the partner involved who’s confidence had been shaken by this – I think he valued my support. |
| Describe a change made to your practice as a result of a significant event (either one you were personally involved with or something that happened to someone else that has affected you) | We have had a number of abnormal results go “astray” this year this has been discussed on 3 occasions at our team meetings. We now have a system in place to ensure all results are seen, action indicated and that the action is carried out. It has meant that I take longer reading the mail but it seems (so far) to have eliminated mistakes |
| What do you think about significant event analysis? | Initially I was a bit wary about washing dirty linen in public. It is however now a valuable part of our practice leading to minor changes to improve the practice and patient safety |