Aims and Objectives.
Aim –
Objectives –
Enhanced Significant Event Analysis has been used for some time in industry to improve performance. In dentistry performance improvement may mean better patient care, patient safety, clinical treatments, staff performance, efficient running of a practice or profitability. We learn through what we do every day. For example, after struggling with a difficult extraction and finally figuring out how to remove the tooth, the next time a similar extraction is attempted we apply what we learned, and the event becomes less traumatic for the dentist and patient.
Dentists perform mini significant events analyses every day but there is a tried and tested process to help us make the most out of an event and this can involve the whole team. Thinking about an event and analysing it thoroughly can bring enormous benefits. One of the barriers in General Dental Practice is lack of time to review something that has happened and learn from it. Often opportunities are missed, and the same old mistakes are made in the future.
It is worth making time to analyse significant events in practice and involve the whole team. Going through the process helps develop a train of thought which can be applied every day. Staff will also feel empowered.
Enhanced SEA aims to guide health care teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on the staff involved. Taking this approach will help to openly, honestly and objectively analyse incidents, particularly more difficult or sensitive safety cases by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the event happened. Applying human factors involves looking at the interaction between the individuals involved; the clinical staff, patients, people outside the organisation (like secondary care or a laboratory), the activity that was taking place; (was this complex?, were there guidelines or protocol to follow?, was the equipment correct for the job?) and the environment; (staffing, rooms, communications, training, culture).
eSEA is normally used when something has not gone well but can be used to study when something has been a success. This information can be shared and used to improve others’ practice.
This section of Turas contains real life examples of which dentists have submitted to NES and have been approved for NHS QIA. Through sharing these examples, it is hoped you may benefit from the experiences and learning of others to improve your own practice.
A good analysis of an incident will lead to a good action plan for improvement.
In this section there is guidance about what makes a good analysis and there are comments about each of the event reports.
Think about the overall aim of carrying out an analysis. The aim is to improve something within your practice. This will require some sort of change to take place. To make a change or changes there must be plan. This is your action plan – what needs to be done, who will do it and by when. All good eSEAs have a robust action plan. Noting things were discussed at a meeting and people agreed to pay more attention to something or a new idea was going to be considered is not good enough. Real change requires more work!
The event needs to be investigated. It is best to do this as soon as possible after the incident. This requires gathering and recording of evidence. Talk to all the people involved, check physical evidence (like when a piece of equipment failed or reviewing clinical notes) and gather any other relevant information. This may be difficult especially if it involves a mistake by a member of staff. It needs to be done sympathetically, staff will not tell the truth if they feel threatened or they are going to be disciplined. A good eSEA report will detail how and what evidence was gathered to find out why the event developed as it did.
Based on the above think about the consequences of the issue. Who/what did this effect? How bad was it? For example, it may have affected a patient in terms of sub-standard treatment, inconvenience, staff may have been upset, the practice may have looked bad in the terms of reputation or may have wasted time and lost income. A good eSEA report should have a broad perspective of the ramifications from the incident. This is often best achieved by speaking to as many people as possible in the practice at a special meeting.
A good analysis will now explore in detail why the event happened. This is where issues and mistakes can be identified. It is often the case that an event is the result of several things going wrong in a sequence with many people involved and a good e SEA will manage to uncover the layers behind this. Therefore, it is important to speak to all involved. At this point a good eSEA will investigate human and systems factors that have contributed to the event. Find out how the people involved behaved and why – for example did someone attempt a task that they were not capable of? Why did they do this? Was a patient difficult to treat because they were demanding or nervous? Was there a communication problem? Look at the overall picture in the practice on that day. Was there an unusual problem with equipment or the premises or the workload which contributed to the event? Then look at the overall picture of the practice/clinic/management structure and culture of your organisation. Did this have an influence on why the incident occurred?
Not every incident will have all the above influencing factors, it will depend on the complexity of the event.
Having examined the above information the next stage is to reflect on the event. A good eSEA report should contain a reflective analysis. From this you will be able to learn how to avoid the same issue recurring and hopefully on a wider basis learn about behaviour, training, knowledge gaps, communication or organisational systems which could be changed to improve practice performance in other areas too.
What you have learned from the event needs to be applied to your practice, or for some events the wider organisation too - such as across a group of practices. A good eSEA report must contain an action plan. Think about what lessons have been learned at different levels across the practice - individual, team, organisation. List what learning needs the event analysis has uncovered, such as poor induction processes for staff or lack of training.