Significant Event Analysis

1. Significant Event Analysis

2. Objectives • 1. Be able to describe significant event analysis/audit (SEA) and the potential of its use. • 2. Know how to use significant event audit for your own learning and continuing professional development. • 3. Know how significant event audit can be used to drive organisational learning and change.

3. What is SEA? • Occurs when “individual cases in which there has been a significant occurrence (not neccessarily involving an undesirable outcome for the patient) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care and to indicate changes that might lead to future improvements”. (Pringle et al 1995) • Also known as critical event audit, critical incident analysis, structured case analysis, facilitated case discussion.

4. History • Grand round, clinical pathology meetings, M&M meetings, Confidential Inquiries – traditionally focus on failure and heirarchical structure. • 1999 Clinical Governance • “A First Class Service”, “Building a Safer NHS for Patients” • 2004 SEA introduced to QOF • Part of appraisal and future part of revalidation

5. What is a significant event? • WWII aviation psychologist Flanaghan definition • Negative vs. Positive • Examples: • Prescribing error • Failure to action abnormal result • Missed diagnosis • Failure to refer • Breakdown in communication • Breach of confidentiality

6. Epidemiology • One PCT: • 26.7% events involved patient safety • 6.5% serious/life threatening • 19.9% potentially serious • 28.5% involved medicines management

7. Aims of SEA • Identify key events and learn lessons to improve patient care • Instigate a no blame, open culture with reflective learning • Team building and support after stressful episodes • Identify good practice • To be a tool for CPD • To share SEA between teams where events occur at overlap eg OOH, discharge problems.

8. Questions to be answered • How could things have been different? • What can we learn from what happened? • What needs to change?

9. The Process • Logbook, meeting • Collect info • Hold meeting, choose facilitator • Analysis of event • Report back on progress on agreed actions • Write report • Seek feedback

10. Significant Event Analysis – Cumbria VTS proforma • What is the significant event? • Why is it a significant event? • Who is involved? • What factors led to this event? • How was the event handled? • How could it have been handled differently? • What action needs to be taken as a result of this event? • What lessons can be learnt for future reference?

11. Outcomes • Congratulation • Immediate action • Conventional Audit • Further work needed • No action

12. MCQs 1 .Significant event audit is also known by the following names: • Critical event audit • Critical incident analysis • Structured case analysis • Facilitated case discussion • Criterion-based audit 2 .Significant event audit must involve a death or ‘near miss’ event. • True • False 3 .The most appropriate way to undertake significant event audit is alone in private, or with a clinical colleague from the same discipline. • True • False

13. 4 .The following are helpful rules for setting topics for significant event audit: • Choose a recent event that has stuck in people’s minds • Select a paper or editorial from the latest issue of the BMJ and search for a case that matches the topic • Choose a case that raises issues about interprofessional communication and working • Choose a case where the main thing that went wrong was the fault of someone on another team • Choose a case which the group don’t want to discuss but which one or two people ought to be made to focus on • 5 .Organisational and administrative issues are inappropriate areas for discussion in significant event audit if clinical outcome was not compromised. • True • False 6 .In a team meeting to discuss a recent critical incident, it is recommended that: • The senior partner or his/ her deputy should chair the meeting • Reception staff could meet with the practice manager beforehand to discuss what they are going to say • A report about which individuals made the wrong decisions should be drafted • Staff learning needs should be explicitly identified • A date of next meeting should be set

14. 7 .In significant event audit, discussion should focus only on the facts of the case, and staff should be discouraged from discussing their emotional reactions. • True • False 8 .In relation to confidentiality, when a group discussion is held on a case relating to a patient: • Reception and administrative staff should not be present • Any notes should be given a code number rather than the patient’s name • No written record should be kept of the discussion • Audio or video recordings of the discussion may be made and transcribed • The case may be published if the patient is given a fictitious name 9 .When giving feedback to the person who has presented a case for group discussion: • Write down your feedback and pass it confidentially to the person rather than say it out loud • Try to say as many positive things as negative • The person who has presented the case should be invited to make the first comment • Highlight aspects of the person’s personality that might have influenced the outcome of the case • Write concerns and suggestions on a flip chart

15. 10 .Once issues have been raised and discussed, a specific standard of performance should be set in relation to key areas of concern. • True • False 11 .In research studies, the following have been shown to be areas of concern for primary care staff in relation to significant event audit • Insufficient protected time available for discussion of sensitive cases • The fear of making things worse rather than better • Poor facilitation skills of the person leading the discussion • Role conflict when junior staff are asked to adopt ‘egalitarian’ ethos in group meetings • Concern from non-doctors that the doctors’ agenda tends to dominate the meetings

16. SEA example • Jonathan Brown, a GP registrar who had been in post for one month, was sent out on a visit at 11am last Wednesday. A receptionist had taken the call and passed on the message, explaining to Dr Brown that the family was generally “demanding and anxious”. • The patient was a 15-year-old girl of Punjabi origin with a rash and fever, attended by both parents and a grandmother. The girl spoke excellent English but was shy and hiding behind a veil; her parents spoke little English and the grandmother none. Dr Brown visited immediately but felt uncomfortable about performing a close physical examination, as the family were clearly observant Muslims. He diagnosed chicken pox from the history and the mother’s description of the lesions, reassured the girl and her parents, and suggested over the counter paracetamol and calamine cream.

17. Later that night the girl’s father dialled 999 and she was admitted to hospital. The diagnosis was indeed chicken pox but it was accompanied by pneumonia and disseminated intravascular coagulation (a rare and life-threatening metabolic complication). • Happily the girl is now recovering, but she spent three days on the intensive care unit and might have died had her father not called the ambulance during the night. The practice had access to a Punjabi interpreter but Dr Brown was not aware of this.

18. I.  The person to blame for this ‘near miss’ tragedy is Dr Brown • No

19. II.  This case would be very suitable for a significant event audit  • Yes

20. III.  The best time for a significant event audit meeting would be in the evening after surgery • No

21. IV.  The only information that must be reported in meticulous detail at the meeting is the feelings of the people involved • No

22. V.  Because the case involves Dr Brown, he should invite a representative from his defence society to accompany him to the meeting • No

23. VI.  Significant event audit could also be termed ‘criterion based audit’ • No

24. An example of an SEA • 78 year old gentleman • PMHx: Type II DM, HTN, IHD • Attended with frank haematuria • No Hx of prostate Sx or problems • Fast tracked to Urology and found to have a superficial TCC – fully resected

25. On review of notes had had 6 month Hx of recurrent UTI and microscopic haematuria which was treated as LUT’sx and not referred ? Missed bladder cancer which could have been diagnosed earlier

26. Questions to ask? • Was this a missed bladder Ca 6 months previously? • The GP seeing him for the last six months now retired – how much clinical responsibility does he or she still hold? • Does it make a difference if all TCC now resected • Has any harm been done? • Will we damage doctor pt relationship by telling him? • Does patient have a right to know what happened? • Retraining need for staff involved?

27. References • Pringle M, Bradley CP, Carmichael CM, et al; Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care. Occas Pap R Coll Gen Pract. 1995 Mar;(70):i-viii, 1-71. • Greenhalgh T. Significant Event Audit, last revised 2006; Doctors.net.uk CME module • FLANAGAN JC; The critical incident technique. Psychol Bull. 1954 Jul;51(4):327-58 • http://projects.exeter.ac.uk/sigevent/ • http://www.patient.co.uk/doctor/Significant-Event-Audit-(SEA).htm • www.pennine-gp-training.co.uk/Significant-Event-Analysis.doc • www.gp-training.net/cme/appraisal/docs/sigevent.doc