When something goes wrong

If you're involved in an adverse incident, learning from what went wrong or right should help improve patient care.

The GMC expects you to be open and honest if things go wrong and co-operate with any formal inquiry into the treatment of a patient.
Learning from incidents is a key part of the NHS complaints procedure.
Assessing and monitoring the quality of service provision is an essential standard for Care Quality Commission (CQC) compliance.

In order to revalidate, you'll be expected to provide evidence at your appraisal that you have participated in significant event analysis.

You should incorporate reflection on adverse events into your professional practice.

Identify the incident

The first step in the process is to identify the incident. Examples of incidents that you might report include:

unexpected deaths
delayed or missed diagnoses
medication errors
communication failures.

You should report any circumstance where you believe something has gone wrong even when the patient has not come to harm as it might still be an opportunity to learn lessons and reduce risk.

Your organisation may have specific reporting guidelines, and these should be followed.

Report the incident

There should be an established method for reporting incidents.

Staff should be trained so they know what is expected of them, and reassured that they won't be unfairly or inappropriately blamed either for the incident or for reporting it. Confidence will hopefully build over time if you have a clear, consistent policy in place.

Create a system that's easy to use.
Have in place a simple paper or electronic form for reporting.
The report should be completed and submitted as soon as possible after the event by the person who was involved in, discovered or witnessed the incident.
Reports should be submitted to a nominated individual responsible for overseeing the process, such as the practice clinical governance lead in a GP practice, or the clinical governance/risk management department in a hospital.
The report should be factual and avoid expression of personal opinion.

Act on the incident

The nominated individual should review the data and check that any urgent remedial action is in hand. Many organisations will have a system of classifying adverse incidents, which can then guide the level of investigation and analysis needed.

Organisations will often dedicate regular time slots for incident reviews. The nominated person should judge if the adverse incident should form part of the agenda, and whether it can wait until the next significant event meeting or if more immediate action is required.

Significant Event Audit (SEA)

What is SEA?

SEA is an active approach to case analysis involving the whole healthcare team in an open and supportive discussion of selected cases/incidents.
The aim is to improve patient care by responding to incidents and allowing the healthcare team and, where appropriate, the support team to learn from them.
The emphasis is on examining underlying systems, rather than directing inappropriate blame at individuals.

Such reflective practice is known by several names - significant event analysis, untoward incident analysis, critical event monitoring.

It's likely that events identified will come from a variety of sources; for example, incidents that occurred in clinical, administrative or organisational areas, and patient complaints.

Collecting evidence

The nominated individual or their staff should collect factual information about the incident from those directly involved and any others who witnessed it -for example, patients and their relatives.
It's also important to review clinical records, and to identify any relevant policies and guidelines.

Confidentiality

Protect patient confidentiality, particularly if information is to be submitted for local clinical audit.
Let patients know that their data may be used in this way and give them the opportunity to object.
In general practice, patients can be informed through waiting room posters and practice leaflets.
Anonymise identifiable information before discussion.

Involving the team

Ideally, medical, nursing and other staff should be invited to the SEA meeting. Each will have a different perspective, which may help generate a variety of potential actions. In general practice you may wish to invite management and reception personnel. Attached staff, such as physiotherapists and pharmacists, can also be involved where relevant.

Occasionally, a clinical incident may be particularly sensitive and therefore inappropriate for discussion by the whole team. Often this issue can be avoided by anonymisation of patient information, but if a whole-team discussion is inappropriate, the same review process can still take place with fewer participants.

The SEA meeting

Set aside protected time for the discussion.
It's helpful to have a chairperson with some experience in this type of process. This might be the nominated responsible individual.
It might also be sensible for someone who has not otherwise been involved to attend, so there is an element of independence in the review.

Here are four key questions to consider during the analysis:

What happened?
Why did it happen?
What has been learned?
What has been changed or actioned?

The outcome

The process should result in positive change for the workplace and patients.

Remember, the review can confirm good practice as well as identifying areas that need attention, and more than one outcome can occur in the same case.

If no change is necessary this can be recorded, but if changes are to be made then you should take the following steps:

prioritise the changes to be made
identify any training and skills required
identify other resource implications, for example, purchasing of equipment
devise a plan to meet these needs
agree a timescale for change implementation
nominate a person to be responsible for ensuring current practice is changed
amend protocols/policies where necessary
measure the effects of any improvements, where possible
ensure review and feedback at future discussions. This can be done at the opening of the next SEA meeting.

This final point is what makes it an 'audit' rather than an 'analysis' - it completes an audit cycle.

SEA records

Provide a brief summary of the discussion and the lessons learned.
Update the record once actions are completed so the process is clear.
Completed anonymous SEA records can be used as evidence of reflective practice, for appraisal and revalidation.

Sharing learning

Inform staff of the lessons learned and any proposals for change.

If the feedback is constructive, it should encourage staff to continue reporting incidents, because they will see that information is being acted upon and the system is being operated in a fair way.

You should also consider whether there is a requirement to report the event elsewhere; for example, to the NRLS or the CQC. Certain incidents, such as so-called 'never events', have specific reporting requirements.

Significant event analysis

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