Reflecting on SEA activities
Many have an image of a professional man, complete with deerstalker’s hat and a pipe, lounging in an armchair and contemplating the facts, or alternatively of another adopting the ‘Rodin position’ deep in thought. The image of the loner dealing in abstract concepts is not appealing to all but it need not necessarily be so. The QIA example illustrates the potentially social nature of effective reflection. Jenny Moon, in her advice to students, demonstrates that the processes of reflection need not be ‘abstract’ either. In promoting the concept of written reflection she encourages the reflective learner to clarify their thoughts on the page. This is an important additional tool in the promotion of reflective practice. This is demonstrated perhaps most clearly in the processes of Significant Event Analysis (SEA).
For Deep Vein Thrombosis (DVT) prophylaxis during a hip replacement operation a patient is treated with a New Oral Anti-Coagulant agent (NOAC) and is discharged with the drug listed in her take home medication. The prescribing clerk shows the discharge medication list to a doctor who instructs new medications to be put onto the patient’s repeat medication list. This is duly ordered monthly by the local pharmacy and taken on a daily basis by the patient until a medical representative, intrigued by the dosage being administered, questions the pharmacist who, in turn, sends a query to the practice. It transpires that a drug intended only for a brief period following the operation (i.e. until full mobility had returned) had been inadvertently taken by the patient for over six months.
Fortunately the patient came to no harm. However, on discovering this prescribing error the doctor concerned wrote up, using the standard practice SEA template, the details of this SEA. Following good practice the SEA was circulated to all partners to consider prior to the next practice meeting: all were able to reflect upon the processes and events that had led to the error. Well-informed before the event all-present were able to troubleshoot the case and consider means of preventing a similar recurrence. The agreed actions were listed in the relevant section of the form and circulated again to all colleagues to ensure unanimity. The changes in procedures were added to the practice protocols for action taken on hospital discharge letters.
Reflection Tool: Written reflection encourages the reflective process and helps to crystalize conceptual thoughts.
Point of Interest: You will see on the MARS site under ‘Category' a ‘drop down’ option that provides you with established formats for Quality Improvement Activities and Significant Event reporting.