Significant Event Audits: Share the good news

Dr Richard Stacey encourages practices to think positively when handling an SEA

World War II pilots established the concept of the Significant Event Audit (SEA) to identify effective aspects of combat training.1 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).

The National Patient Safety Agency (NPSA) has produced guidance in relation to SEAs and has identified the following seven stages of the process:

  1. Awareness and prioritisation of a significant event.
  2. Information gathering.
  3. The facilitated team-based meeting.
  4. Analysis of the significant event.
  5. Agree, implement and monitor change.
  6. Write it up.
  7. Report, share and review.2

The focus of this article will be to identify when to carry out an SEA, where the report should be saved and with whom it should be shared.

When should an SEA be undertaken?

SEAs can be particularly important in relation to the management of complaints

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.

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.
  • A complaint.
  • An overlooked referral letter.
  • A difficulty in contacting the practice by telephone.
  • A vaccination either given or omitted in error.
  • A near miss (ie, 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?

Where should an SEA be saved?

The SEA report would be disclosable under the provisions of the Data Protection Act (1998) hence there is no reason why it should not be saved in the medical records.

In addition, 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.

With whom should the SEA report be shared?

The report should be shared with any person or agency that may learn from the incident

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
  • the PCT 
  • the NPSA’s National Reporting and Learning Service
  • the Medicines and Healthcare products Regulatory Agency (MHRA).

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 the patient’s consent should be sought.3

References

  1. Flanagan, JC. The critical incident technique. Psychol Bull. (1954)
  2. NPSA
  3. GMC, Confidentiality, paragraph 7.

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