Significant event analysis (SEA) is an important activity that contributes to risk reduction and helps to improve patient care and practice systems. It involves looking back at previous events, both positive (e.g. the rapid assessment and successful treatment of a patient) and negative (e.g. mis-communication that leads to poor patient care or exposes a deficiency in practice systems) to establish what happened and why and what can be learned from such events in order to implement changes (risk-reduction measures) that will lead to an improvement in patient care and practice systems.
For more details about the concept of and how to conduct a SEA, see the Quality Improvement pages on TURAS [1].
When an incident or problem occurs within a practice it is important that the individuals involved or affected are able to report what happened without being concerned about blame or punishment. What constitutes an incident that should be reported is subjective. A minor event to some individuals might be regarded as major by someone else. For example, an incident might be defined as anything that went wrong (e.g. lab work not being delivered to the surgery) or an event that might have more-serious consequences (e.g. recording on the wrong record card).
Events that are not reported are likely to recur. Learning from mistakes must be looked at in a positive way and steps taken to reduce the risk of the mistakes happening again. There will undoubtedly be examples of incidents, mistakes or simply things that have gone wrong in the practice. These can generally be resolved uneventfully.
Information regarding an incident or event can be obtained from sources such as:
- patient complaints;
- accident book;
- verbal reports from team members.
As a part of your risk management strategy, put in place a system for documenting incidents however minor they appear (see Incident Reporting Form template).
- This will enable you to look at the problem and decide what future steps are required to ensure it does not happen again.
To enable this system to work effectively, ensure that it is non-threatening to staff and has no element of blame attached.
Ensure staff are aware of this reporting system and have confidence in it.
Discuss each incident fully with all members of the team.
- A practice meeting is the ideal forum where everyone has the opportunity to discuss and provide a solution to avoid a recurrence of the event.
NB: It is important not to confuse recording and analysis of incidents with the complaints process or accident reporting. An incident might result in an accident that would be documented for health and safety reasons (see Health and Safety – General), or an incident might result in a complaint that would require to be handled as per the practice’s policy on dealing with complaints (see Communication). The purpose of recording incidents is to try to prevent them happening in the future.