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. The worked examples include one positive and one negative significant event.

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.  

It is important to have a meeting to discuss the event ideally with people involved in the event or if this is not possible with other clinicians e.g Peer support group.

A significant event analysis should include:

  • Description of event
  • Identify the reasons for the event
  • What are the learning points?
  • What changes have occurred as a result?
  • Or use the template on MARS (any of the domains under “revalidation templates”)
Example 1
Description of event
I referred a patient with an inguinal hernia for consideration of surgery, the patient phoned the hospital 3 months after my initial referral to find that he was not on a list waiting to be seen. Further enquiries by my secretary found that there was no record of a referral letter being received by the hospital. We have records of the referral and a computerised copy of the typed letter. We do not have any record of it actually being sent (we have an internal mail collection arrangement with the hospital).
Identify the reasons for the event
I am unsure as to where this letter became lost. With the volume of referral letters leaving the practice there is no way that we can remember this letter leaving but equally it is likely that as it has been typed that it would have been printed signed and sent, it may have become lost at secondary care level.
What are the learning points?
This incident was discussed at a practice meeting with all the doctors present and our secretary. The potential issue of lost letters was seen as one that could not be safely sorted out with a simple change as some of the onus would need to be on our multiple secondary care providers
What changes have occurred as a result?
We have recently purchased a digital dictation system which keeps a list of referrals and the secretary is now noting which referrals have been printed signed and sent – this is an easy change as all the mail comes back to her after signing to be placed in envelopes and sent. This solves the issue regarding letters sent but does not address possible lost letters in secondary care. The possibility of the secretary checking that every referral had been received was seen as too time consuming and a compromise solution is to ask the patient to contact the surgery if they have not had an acknowledgment letter from the hospital within six weeks – this has created extra workload and this is being monitored but in the 3 months that this system has been running not one letter has been misplaced. Urgent referrals are chased up by our secretary within a week to ensure receipt and action.

Example 2
Description of event
A patient’s wife attended worried about her husband who was very depressed due to the pain in his hip, he was on the local waiting list for consideration of hip replacement but had a further 9 months to wait for out patients. I arranged a consultation with the patient himself and it was evident despite moderate opiate analgesia that his constant pain (including night time pain) was getting him down. He had tried to bring forward his appointment but had been told that this was not possible. I spoke to the orthopaedic consultant who pointed out that his urgent waiting list was 9 months long and that he would need to increase analgesia and wait. I managed to get the patient placed on a cancellation waiting list.
Identify the reasons for the event
Long orthopaedic waiting lists (see also in my section on constraints affecting my working practice)
What are the learning points?
To contact the relevant department secretary to enquire about cancellation lists.
What changes have occurred as a result?
I will consider using this avenue in future for cases that cannot wait



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