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Learning from significant events

Significant event audit is a formal way of analysing and learning from incidents at your practice, writes the MDU's Dr Sally Old.

Meetings allow staff members to contribute to the audit process (photograph iStock)
Meetings allow staff members to contribute to the audit process (photograph iStock)

Significant event audit (SEA), when carried out effectively as part of your practice’s clinical governance procedures, should enable you and your team to highlight examples of good practice and learn from things that have gone wrong. This process will help you to improve the quality and safety of patient care, develop a culture of openness and work effectively as a practice team.

SEAs are an important aspect of CQC regulation. Key lines of enquiry for the CQC include ‘Learning when things go wrong’ and ‘Learning improvement and innovation’. In an outstanding practice the CQC expects to see  that ‘Learning is based on a thorough analysis and investigation of things that go wrong’.1

SEAs are also an important aspect of ethical practice: the GMC requires doctors to 'take part in systems of quality assurance and quality improvement to promote patient safety' and you are likely to be asked to discuss and reflect on your involvement in this during your annual appraisal.

What to audit

All practice staff should understand the need to identify events with implications for patient care and know how to complete standard incident forms.

A designated person, usually a senior GP or the practice manager, should then be responsible for gathering information about an incident, including personal testimonies. They will need to classify and prioritise the incident by degree of harm and consider whether the case should be the subject of an SEA. The NRLS eform for reporting incidents guides users through the classifications of no harm, low harm, moderate harm, severe harm or death.

This is essentially a structured root cause analysis of the incident to determine what happened and why; agree what lessons need to be learned; and ensure the necessary action is taken.

SEAs are ideal for analysing more complex cases which have implications for the overall quality of care, particularly system failures. They are not intended to apportion blame, so one-off mistakes by individual members of staff should probably not be the subject of an SEA, unless there is suspicion they are the result of underlying system factors, such as confusing protocols or staff shortages.

Incidents which may be suitable for SEA include adverse events, for example, missed diagnosis, a prescription mix-up or computer failure. However, bear in mind that useful lessons can also be learned from discussing positive outcomes like a thank you letter from a patient so good practice can be celebrated too.

SEA meetings and outcomes

In some cases, a meeting can be useful to allow others in the practice to contribute to the audit. To be effective, such meetings require careful preparation and protected time. For example, it is important to know in advance:

  • Who will chair the meeting: it is important that they are experienced in facilitating open and honest discussion and keeping everyone focused on the matter at hand.
  • Who will take the minutes.
  • The ground rules: meetings should not be allowed to degenerate into argument.
  • Who will attend: all staff should be encouraged to participate, including those in non-clinical roles where they are able to contribute to the discussion.
  • The cases to be discussed.
  • The information which should be circulated beforehand.
  • How often SEA meetings will take place.
  • How you will ensure action plans are reviewed.

In its quick guide to SEAs, the NHS guidance suggests a number of possible outcomes:

  • No action required
  • A celebration of excellent care
  • Identification of a learning need
  • A conventional audit is required
  • Immediate action is required
  • A further investigation is needed

Sharing the learning

Where it is decided that further action is necessary, the designated person should agree an implementation plan with relevant staff. The plan should:

  • Set out and prioritise the changes required.
  • Include identified training or resource needs.
  • Draw up a timescale.
  • Nominate a project leader.
  • Ensure feedback at future meetings on progress to date.
  • Review and update practice protocols where necessary.

Next steps

A detailed, written record of SEA is essential to demonstrate that it was completed satisfactorily. Reports should always be anonymised to protect the confidentiality of patients.

It is a good idea to include details of the event, including the date and who was involved; your reflections on what went well and what could have been done better; the changes which have been agreed as a result; and their effect. Your practice should retain copies of SEA paperwork and you may also want to keep your own notes for discussion in your appraisal.

Finally, there is limited value in carrying out an SEA if the learning is not shared. The CQC expects practices to report incidents to the National Reporting and Learning Service (NRLS) where patient safety has been or could have been compromised.

NHS England has devised an 'e-form' designed specifically for general practice staff to submit these patient safety incident reports. It allows practices to submit a report entirely anonymously, or to choose to include their practice code. There is also an option to request an acknowledgement email with an SEA template which can be used for appraisal and revalidation and evidence for CQC inspections.

As well as reporting to the NRLS, your practice could also consider sharing lessons with other practices in your area, such as those in your CCG.

You can find more information about the NRLS here.

Duty of candour regulations

The duty of candour regulations for GP practices came into effect on 1 April 2015. The regulations set out some specific requirements that providers must follow when things go wrong. You can find more information on this here.

The MDU can arrange an on-site training seminar for MDU Groupcare members on learning from significant events

  • Dr Old is a medico-legal adviser at the MDU

1. Key Lines of Enquiry, prompts and ratings characteristics for healthcare services – CQC. https://www.cqc.org.uk/guidance-providers/healthcare/key-lines-enquiry-healthcare-services

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