Patient Safety Zone

SEA involves a structured team meeting, where participants reflect on and analyse identified significant events to understand what happened, the impact and contributing factors. This leads to reflection and learning to direct improvements to systems.

A description of how to use enhanced SEA and a worked GP example are included below. Six eLearning modules that are based in different clinical settings (including GP) are also available.

Learning Event Analysis (previously called Significant Event Analysis), is a retrospective educational activity where those involved in an event, reflect on and analyse the event at a structured team meeting. Learning events can be events where something has gone wrong or nearly gone wrong (so-called “near misses”) – for example, test result communication issues or prescription errors. Alternatively, they can be episodes where there was good care. This team discuss the scenario, explore the contributing factors and their relationships, reflect on and prioritise learning, share good practices and identify actions for improvement. LEA presents an opportunity for teams to review events using a People-Activity-Environment (PAcE) Analysis approach based on Human Factors principles. By reviewing complex system interactions, rather than solely focusing on personal responsibility, a greater systems-based understanding of how significant events occur can be obtained, as well as their impact on performance (e.g. patient safety, efficiency, productivity) and people’s wellbeing (patient and staff health, safety, satisfaction, experiences).

This QI method directs care teams to analyse, reflect and learn from studying an event. This leads to changes to improve the care system.

• It is an established learning method in primary care settings that uses reflection and analytical skills to support improving patient safety.

• It is about looking at the wider system interactions using a PAcE Analysis to understand why events occurred and learning from them

It is not a method that seeks to criticise the actions of individuals and organisations or apportion blame

The event analysis should be led (and written-up) by someone directly involved in the incident where possible

• Identify and prioritise an event for analysis.

• Collate as much factual information on the event as possible; including written records.

• Convene a meeting to discuss and analyse the significant event.

• Undertake a structured PAcE analysis of the significant event:

    o Explore impact and potential impact of event.

    o Identify contributing factors by exploring the interactions between, the people involved, the activity they undertake and the wider environment within which they work.

    o Identify learning from event (e.g. at individual, practice, Board levels).

    o Agree actions to improve systems.

• Monitor any changes agreed and implemented.

• A written record (report) of every LEA is undertaken.

• The findings from the report should be shared and reviewed with GP team members.

It should involve all relevant members of the primary care team, including all appropriate non-clinical staff, for effective communication and to ensure learning is shared with all involved parties

• All normal Top Tips (listed on page four) for QI apply here.

• Avoid medical domination of meetings that may accidentally exclude non-clinical staff from participating effectively.

• Action from LEAs should be concrete and clear and agreed by discussion of the whole team prior to writing the LEA up.

• Remember ‘positive’ events and learning from everyday care, which are often not chosen due to care teams perceiving greater value in resolving ‘negative’ issues.

• Reports should not contain details that allow identification of patients (such as initials). Indeed staff involved should be referred to as 'nurse A', 'Dr B', 'admin C', 'pharmacist D'

More information can be found here.

The report template can be downloaded from here.