Significant event audits

Medical Protection explains how Significant Event Analysis (SEA) work and in what scenarios they would need to be undertaken.

Second World War pilots established the concept of the Significant Event Audit (SEA) to identify effective aspects of combat training¹ and since then the medical pioneer of SEA in primary care has been Professor Mike Pringle (CBE, FRCP).

Today, SEAs are an integral part of modern clinical practice and demonstrate not only a spirit of reflective practice, but also a culture of openness. The aims of an SEA are as follows:

• To identify the factors that led to the incident (and areas of good practice).
• To establish how those factors could be changed in order to prevent a similar occurrence in the future.
• To implement any necessary changes (and reinforce areas of good practice).  

When should an SEA be undertaken?

The short answer to this is that an SEA should be undertaken in relation to incidents when there has been, or could have been, a significant adverse outcome.Significant events do not always reflect bad practice.

Examples might include:

• An unexpected death
• A suicide attempt
• An unexpected hospitalisation
• An adverse clinical outcome
• A delay in diagnosis
• A misdiagnosis
• A prescribing error
• A breach of confidentiality
• An overlooked referral letter
• A difficulty in contacting the practice by telephone
• A vaccination either given or omitted in error
• A near miss (i.e. when there was no adverse outcome, but there was potential for the same).

SEAs can be particularly important in relation to the management of complaints. A recurrent theme when exploring a patient’s motivation to complain is that in addition to seeking an apology and an explanation as to what happened, they also want reassurances that steps will be taken to prevent a similar occurrence in the future.

Explaining to a patient that an SEA is to be undertaken not only reassures them that their concerns have been taken seriously, but also that preventative action will be taken. Why not offer to share the SEA report with the patient or even invite them to participate in the meeting?

An SEA may also be important when there has been a patient death. The SEA may be utilised as part of the Inquest process or may trigger the practice to consider their reporting requirements to external agencies. 

How should an SEA be undertaken?

The Care Quality Commission (CQC) suggest that SEAs have the following aims which may be helpful for providers to consider when undertaking an SEA:²

• identify events in individual cases that have been critical (beneficial or detrimental to the outcome) and to improve the quality of patient care from the lessons learnt.

• instigate a culture of openness and reflective learning, not individual blame or self-criticism
• enable team-building and support following stressful episodes
• enable identification of good as well as suboptimal practice
• be a useful tool for team and individual continuing professional development, identifying group and individual learning needs
• share learning between teams within the NHS where adverse events occur at the 'overlap' or in shared domains of clinical responsibility (such as out-of-hours, discharge problems).

The RCGP also has a toolkit which provides a structure for undertaking an SEA and suggests that the following areas are reviewed³:

What happened
Why it happened
What has been learned
What has been changed

Where should an SEA be saved?

The practice might wish to keep a copy of the SEA report in a central file for the purposes of implementation of changes and ongoing review. An SEA should not be stored in the medical records

With whom should the SEA report be shared?

Always word the SEA report with the anticipation that it will be shared with the patient. The report should be shared with any person or agency that may learn from the incident; this may include:

• the primary healthcare team
• the community pharmacist
• LFPSE (Learn from patient safety events) service which replaces NRLS
• the Medicines and Healthcare products Regulatory Agency (MHRA)

Some incidents may also require reporting to the CQC⁴. The CQC has a specific list of incidents which require reporting along with regulations regarding the death of service users.
There may be times when a primary care provider is asked to provide input into an SEA conducted by secondary care and vice-versa. For example when communication between 2 providers has resulted in an adverse patient outcome. It is advisable to ensure any input into these SEAs is recorded accurately before the SEA is finalised. 

Finally…

Remember that there is an obligation to inform patients how their information is shared within the primary healthcare team and, if information is to be shared with an external agency in an identifiable form, then confidentiality guidance and the exceptions to this should also be considered in line with GMC guidance⁵.

References

¹Flanagan, JC. The critical incident technique. Psychol Bull. (1954) 
²GP mythbuster 3: Significant event analysis (SEA) - Care Quality Commission (cqc.org.uk)
³Patient safety toolkit: Significant Event Audit (rcgp.org.uk)
⁴www.cqc.org.uk
⁵Confidentiality: good practice in handling patient information - ethical guidance - GMC (gmc-uk.org)