Significant Event Analysis (SEA) – Significant Events, Serious Incidents and GP Learning Events – What are the Differences?
Patient safety is central to General Practice, with learning from mistakes or “near misses” an important personal learning and practice / professional responsibility. However, wording can be confusing as Significant Event Analysis and surrounding processes mean different things to different organisations.
The GMC definition is:
“A significant event (also known as a SI – serious incident, SUI – serious untoward incident or CI – critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented.”
If an event does not reach the GMC threshold for harm but nevertheless presents an opportunity for learning, then this may be referred to as a Learning Event Analysis
Practice managers and GPs need have to a clear understanding of statutory, professional and contractual expectations and processes that need to be followed when a Significant Event occurs. It is important that any patient complaints lead into a process, if appropriate. Often, complaints are generated because patients wish learning to occur to prevent anyone else from having to go through something preventable and a SEA process is a way of achieving this.
What is a Significant Event
- This is where a patient came to harm, or
- Where a patient could have been harmed, or
- Where an event occurred that should have been prevented
Examples of Different Types of Significant Events-
- Equipment malfunction
- Same name patients getting muddled
- Process/system failure with regards to a referral going astray
- Delay to home visit resulting in patient deterioration
- Confidentiality breach
- A phone appointment that was requested which was not done
- Staffing problems
- Prescribing errors
Information about SEA from CQC can be found here:
This states “We want to see evidence of learning from incidents and improving quality. On inspection we look for the impact and learning that has resulted from the SEA. We expect ‘good’ practices to ensure that the learning from SEAs involves the whole team and becomes embedded in everyday practice.
We would consider this under key line of enquiry (KLOE) S2: Are lessons learned and improvements made when things go wrong?”
Practices may specifically want to consider:
- All staff should be aware of the practice procedure and be able to raise a significant event
- Scheduling regular team meetings to discuss, investigate and analyse significant events including:
- what happened and why?
- how could things have been different?
- what can we learn from what happened?
- is change required, if so, what needs to change?
- How to record the outcome of the meeting, what is to be changed / implemented and how, and when, this will be monitored / reviewed.
- How this will be shared, as necessary, with the whole team.
It should be noted that CQC requires direct statutory reporting of some adverse events, such as a death on the premises if the death occurred whilst providing care.
- while a patient was in consultation with a healthcare professional
- while at your health centre, practice or surgery
- during a home visit
Also, you must also notify deaths that occurred within two weeks of a clinical interaction with practice staff if the death:
- was, or may have been, as a result of the care or how it was provided, and
- could not be attributed to the course which the illness or medical condition would naturally have taken if the deceased had been receiving appropriate care and treatment.
Source:. GP mythbuster 21: Statutory notifications to CQC | Care Quality Commission which also clarifies all the statutory notifications that must be made to the CQC regarding events and incidents
Practice Managers should also familiarise themselves with the guidance from their ICB on adverse events. The ICB Patient Safety and Risk team could be useful sources of advice and support. They will investigate certain events involving GP practices or events reported by a GP about other providers. This may involve submitting an adverse incident form which can then be followed up on the Ulysses system or Datix system. Ulysses is an online risk management platform and Datix is an alternative incident reporting system. Your ICB contact will be able to advise which is the correct system to use locally, or if there are alternative pathways in your area.
There are different levels of reporting, depending on how serious the event
- Within the organisation for minor issues e.g. to the Practice Manager and Senior Partner
- ICB/NHSE for more serious events
- National reporting for the most serious events, with actually or potentially greatest harm.
For further information visit – NHS England » The NHS Patient Safety Strategy
Learning from patient safety events is important to improve patient safety.
“The Learn from patient safety events (LFPSE) service
The LFPSE service is replacing the National Reporting and Learning System (NRLS). This new system, managed by NHS England and NHS Improvement, is a major upgrade. It creates a single national NHS system for recording patient safety events. It is a centralised system to record and analyse information. It is hoped that the new system will increase recording. This will allow for more effective learning from events, with patient safety improving.
Primary care staff are encouraged to use the system to record any events where:
- a patient was harmed or could have been harmed. For example, an unsafe discharge.
- there has been a poor outcome, but it is not yet clear whether an incident contributed or not.
- risks to patient safety in the future have been identified.
- safe and effective care has been delivered that could be learned from to improve patient safety.”
GP Learning Events as Part of Appraisal and Revalidation
For GPs Who Have Been Involved in a Significant Event
SEAs also form part of appraisal, and the same case discussed in a team meeting, could be used for an appraisal entry even if a GP is not personally involved, and reflected upon. The GMC requires GPs to declare and reflect on these events at appraisal if they have been named in them, and this is underpinned by the GMC professional duty of candour which states:
“a Your duty to be open and honest with patients in your care, or those close to them, if something goes wrong.
b Your duty to be open and honest with your organisation, and to encourage a learning culture by reporting adverse incidents that lead to harm, as well as near misses”
Therefore, part of a doctor’s professional responsibility is to report adverse events and promote a culture of learning in response to any near-misses or events where harm has occurred.
It is important to remember that there should be no patient identifiable information in any SEA presentation, minutes or shared learning record. Just removing a name may not be enough if the patient is easily recognizable due to other details.
For GPs Who Have Not Been Involved in a SEA
GPs who have not been personally involved in a SEA should do some GP Learning Events for appraisal. This can form part of Quality Improvement Activity.
They could, for example, do some reflection around a practice SEA meeting and demonstrate learning.
Sessional GPs who may find it challenging to attend SEA meetings if they do not have a main base could ask a practice to invite them to share learning or could attend sessional GP meetings where locums can present SEAs and share learning and reflections together, which could then be written up as an appraisal entry.
SEA and GP Learning Event Resources:
This RCGP page talks about SEA in the context of appraisal Guide to supporting information for appraisal and revalidation (rcgp.org.uk). (In “Review of Practice: Evaluating and improving your professional practice”)
This page shares case studies with worked examples of teams, cases chosen and how learning was shared and how this was shared for evidence for QOF payments. 1920-qof-quality-improvement-case-studies.pdf (england.nhs.uk)
This page offers some tools which may be useful: Four tools to enhance significant event analysis in primary care (health.org.uk)
GMC guidance on duty of candour Candour – openness and honesty when things go wrong – GMC (gmc-uk.org)