Significant event analysis
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. Two examples are given below, one a positive experience and the second, negative.
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.
A template is available here.
| 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. |
Example 2
| Title of event |
|---|
| Mistaken identity and breech of confidentiality (giving out a patients address) |
| Date of event |
| 17/1/14 |
| Date of SEA meeting |
| 1/3/14 |
| Personnel present and role |
| All GPs, senior nurse, senior receptionist and practice manager |
| Description of event |
| A patient asked for his repeat prescription at the reception desk. He was handed a prescription for a patient with the same name (but different address). Fortunately this was noticed by the pharmacist prior to dispensing. |
| What went well? |
| Good relations with a vigilant pharmacist and their checking procedures are working well |
| What could have been done better? |
| The main reason was not asking the patient for his name and address before giving the prescription out. |
| Reflections on the event (consider Knowledge skills and performance· Safety and quality· Communication partnership and teamwork· Maintaining trust) |
| At a multi disciplinary meeting the issuing of prescriptions in general was examined, it was felt that the system for review of patients could be strengthened and that fewer of the receptionists would be involved in generating repeat prescriptions. The specific issue highlighted the risk of mistaken identity and the importance of checking patient details until identity firmly established. |
| What changes have been agreed?(Personal or Team) |
| The LHB are running some training days for staff involved in prescribing and rotas will be changed to involve only 3 receptionists in generating prescriptions. These 3 receptionists will attend the LHB course. |
| Changes carried out and their effect |
| A poster has been placed behind the reception desk that states “check name and address of patients collecting prescriptions, obtaining results or booking appointments. If unsure check date of birth” The relevant receptionists are booked onto the LHB course |
Repeat prescribing
In this section demonstrating your relationship with patients it may be appropriate to find out how your patients feel about your repeat prescribing system. The questionnaire could be used to canvass the views of 30-50 of your patients.
Once you have collected in the responses you should reflect on the scores and any comments. You may wish to include these reflections as an appraisal entry and retain the questionnaires as additional supporting materials.
Example of analysis of the questionnaire
In general the patients seem satisfied with our repeat prescribing system – no serious problems were identified. What I did find surprising was that about a third of patients did not know why they were taking their medication. This is something the practice (and myself) should tackle at medication reviews.