Significant Event Reviews (SERs)

Practice Leads

  • Doctors: Ramesh Mehay & Pardip Sandhu
  • Nurse: Zoe Booth

Date Reviewed

6th July 2016

Date of Next Review

September 2017

Ashcroft Surgery is committed through its friendly, supportive and collaborative culture to provide an environment where staff can feel they can raise concerns or explore areas of difficulties, uncertainties and unknowns.    This includes significant events.  It is important to review significant events because often there is something we can learn from them to help us with our patients in the future.  Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of planning) or a deviation drom the process of care that may or may not cause harm to the patient.   Patient harm can occur at the individual or system level. And medical errors can contribute up to a third of all deaths.  Learning points can be for the individual or for the organisation as a whole.   In discussing significant events, we are not trying to apportion blame but instead help individuals and the organisation learn and thus continue to professionally develop.   Such discussions may help to prevent further errors on an individual and system level thus protecting other patients.   Ashcroft Surgery is an organisation which pays high regard to its educational and learning environment because we know it is that which enhances patient safety.

At Ashcroft, we have a system to record significant events as they occur within our clinical system, SystmOne, to ensure we capture these as early as possible.  This process works - we have used this system since July 2010 and we have a documented numerous significant events since this date.  Our process is a multi-disciplinary one – involving doctors, nurses and other groups where relevant.   We are aware that the discussion of specific events can provoke powerful emotions which can adversely affect learning if not properly handled.    However, the same emotions can be harness to achieve change and we do that by providing space for such discussions in a culture that avoids allocating blame and instead focuses on understanding and an opportunity to do things better.  Lessons and actions points are shared with relevant others, electronically or face-to-face to capture those not in attendance.

A recent example of this was the development of “Non-visible haematuria” pathway.  A case discussion from an individual patient highlighted the need to improve the current system.  A team discussion led to the development of a SystmOne protocol-driven template.   This template, at the click of a button, identifies if there are any previous recorded entries of non-visible haematuria in the patient’s medical record and positively prompts the staff to repeat the test and follow the protocol.   This process has worked well and a further follow-up team discussion led to another modification – which was to extend this feature to other clinical areas such as the monitoring requirements for shared care drugs.

Logic dictates that this system should minimise risks to the patient and we a proud to say that we believe this additional and effective safety feature is unique to Ashcroft Surgery.   This example illustrates how our group proactively uses highlighted incidents and potential near misses as learning tools and  through a collaborative team review process how we achieve continuous development – at both an individual and organisational level.   The ultimate aim, of course, is to enhance patient safety.  However, it doesn’t just stop there!  Ashcroft Surgery is one which believes in a culture of learning within a community -  helping others, not just ourselves – derived from principles set by Wenger in his 1998 book ‘Communities of Practice: learning, meaning and identity’.    In  this endeavour, we have met with other local practices (at the regular regional clinical IT group) and presented our ‘new tools’ so that practices can learn from each other, share the resources developed and promote new learning energy rather than continuing to reinvent the old.

What is a Significant Event?

A significant event is an incident which led to unexpected outcomes.  Most people refer to significant events when things go wrong.  In other words, when something bad happens.  However, it can be when something unexpectedly good happens?

Why do we have to look at Significant Events?

Discussion of specific events can provoke emotions that can be harnessed to achieve change. For it to be effective, it needs to be practiced in a culture that avoids allocating blame and involves all disciplines within the practice.  So, analysing Significant Events does several things...

  1. If something bad has happened, it will help you work out what needs to be done immediately to sort the problem out.
  2. Then, once the immediate stuff is sorted, you can then focus on the long term and try and think what measures can be put in place to stop it from happening again.
  3. If something good has happened, we can analyse that good event and work out what specific things led to that good outcome.  In doing so, if we do more of those specific things, then the more likely it is good things will happen.
  4. In doing all of these things, we enhance patient safety and care.
  5. And not only that, but we learn ourselves and develop through the process of doing it.

The Process of Significant Events at Ashcroft Surgery

  • A significant event meeting held once a month in the practices Protected Learning Time (PLT) programme. All doctors and nurses are invited. For non-clinical issues, the relevant admin people will be invited too.
  • All doctors and nurses should understand the importance of raising significant events - i.e. to improve patient safety and as a valuable tool to learn and develop from. We have a no-blame culture in the practice.
  • When a doctor or nurse becomes aware of a significant event, the process and outcome is recorded on our clinical management system (SystmOne) under a dummy patient called ‘Mr Significant Event’ . SERs should be logged as soon as an incident or near miss is felt to have occurred.
  • For relatively new staff - a proforma is available for those who are new to the process. The copy of the proforma is available as a download on this page for reference (but use the one in SystmOne). The person filling out the form will keep as much information anonymised as possible. Use the NHS number rather than patient name.
  • For more experienced users - we initially used the significant event proforma to record the event and subsequent actions.  However the process of filling in a proforma reduced reporting of adverse events hence we changed the system so that we now write a free text note within the body of the new journal.    The final part of the significant event cycle (with reflections, learning points and actions) can either be recorded as an amendment to the initial entry in Mr Significant Event's record OR the proforma filled in and uploaded next to that medical record entry.
  • That doctor or nurse who recognises the significant event is responsible for ensuring the necessary immediate actions are taken to ensure patient safety and do the right thing (which is part one of the proforma SER template).
  • We aim to have SEA every month, but as a bare minimum every 3 months, in our 2h Protected Learning Time (PLT), the clinical team will go through all significant events listed under ‘MR Significant Event’ since the last review.  The meeting review the minutes of the last SEA to ensure actions have been taken  and look at more long-term solutions to enhance patient safety, practice development and individual/group learning.
  • Anonymised information may be shared with the PCT to: a) give them peace of mind that we are engaging in such powerful learning activity to make things better for the future and b) so that they can share some of our learning points with other practices in the neighbouring area.
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An Example of a Significant Event

So, let’s say you go on a home visit to Mrs. Evelyn Pritchard, but you find that she didn’t request a home visit and is certainly not short of breath as stated.  You go back to the surgery and find that there are two Evelyn Pritchards and the wrong one was scribbled down.  You go and visit the right Mrs. Pritchard only to find that she has now deteriorated so much you need to admit her as an emergency because she has developed LVF.

  • Problem: wrong Mrs. Pritchard’s details were transcribed into the home visit book
  • Consequence this time around: high
  • Risk of it happening again in the future: high
  • Immediate Action You Took: visited the correct Mrs. Pritchard and admitted urgently
  • Long Term Action:
    • You decide that it might be an idea if reception staff took details properly.   However, this is not specific enough.  So you think again and you finally come up with the following ideas…
    • We will develop a “home visit Request Proforma” encouraging all staff to ask for the patient’s name, address, DOB and reason for the request.  You decide you will develop this within the next week.
    • You also decide in 2 week’s time at the practice learning time event you will raise this particular event to all staff and circulate the proforma and get opinions and hopefully get everyone on the same wavelength.
    • Every time a home visit proforma is completed, it is stapled to the home visit book: duty of receptionist taking the call and for it to be stapled immediately after the request to ensure it doesn’t get lost.
    • Finally, you decide to add a little box of “urgent symptoms” which will act as an reminder alarm for reception staff to inform the on call doctor immediately and/or call 999

Examples of what you might look at as a Significant Event

  • medication errors
  • any suicides
  • child/adult protection cases
  • any death occurring in the practice premises
  • new cancer diagnoses
  • deaths where terminal care has taken place at home
  • admissions under the Mental Health Act
  • a significant event, occurring when a patient may have been subjected to harm, had the circumstance/outcome been different (near miss).