Four tools to enhance significant event analysis in primary care

The Health Foundation | Published online 25 August 2016

Significant event analysis (SEA) is a collective learning technique used to investigate patient safety incidents (circumstances where a patient was or could have been harmed) and other quality of care issues.

The project developed a framework and then a series of practical tools, which aim to help people working in primary care to apply the approach.

1. E-learning module

This short ‘read and click’ e-learning module is available as a PDF from the Quality Improvement Hub. It explains and illustrates the principles which underpin the enhanced SEA approach, including sections on: Basic error theory; Human factors principles; Taking a systems-centred approach; and the Enhanced SEA method.

2. Enhanced SEA booklet

The enhanced SEA booklet (PDF), developed by the project team, gives a clear, readable overview of the approach, including the basics of human factors theory and an example story. It aims to help individuals reflect on the potential emotional impacts of a significant event by using these principles to gain a clearer understanding of all of the contributory factors involved.

toolkit

Image source: The Health Foundation

3. Deskpad

In addition to individual reflection, it’s important that teams reflect together on events and analysis. Each sheet of this enhanced SEA deskpad (PDF) contains instructions and prompts to help guide a team in taking this approach to event analysis, and to take notes on what was agreed.

4. Reporting template

The project team also designed and developed a new report format (PDF) for writing up SEAs, which accommodates this approach. This format is recommended for GP specialty training and medical appraisal, as well as for practice manager and nurse vocational training and appraisal.  It is also being used in community pharmacy and dental practice in Scotland.

Read the full project overview here

 

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