Enhanced Significant (Learning) Event Analysis

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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.

Enhanced Significant (Learning) Event Analysis

eSEA 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.

What is Learning Event Analysis?

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).

Why would you choose this?

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

What is it useful for?

• 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

What is it not useful for?

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

Who can do/lead it?

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

How do you do it?

• 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.

Who else does it involve?

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

Top Tips

• 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'

Further Info

More information can be found here.

The report template can be downloaded from here.

About the Significant Event

Please describe what happened

Patient attended a practice nurse for his flu vaccine. Asking questions about his blood pressure and if the nurse would check it while he was in. Accompanied by wife who also asked if she could get a flu vaccination. Accidentally given the pneumococcal vaccine.

What was the impact or potential impact of the event?

The patient was not due the pneumococcal vaccine and developed a red sore arm. Significant anxiety for the GP trainee. Inconvenience for the patient to return for another vaccination. Loss of faith in the practice. Potential for complaint. Potential to not be immune to flu. If this has happened once, could others have received the wrong vaccine?

Contributory Systems Factors 

Please outline the different factors that contributed to WHY the event happened

People Factors Nurse competent but new to the practice. Trying to be helpful. Tired after 3 hours vaccinating patients. Distracted as patient asking about blood pressure and wife asking about her vaccinations.

Activity Factors Long clinic - checking procedures become automatic and less effective. Vaccines stored together in nurse’s room fridge. Both vaccines look very similar and on same shelf.

Environment Factors Five minute appointments, small room with poor lighting. Vaccines on same shelf. Pressure to get through as many patients as possible


Please describe how these factors combined to make the event happen.

Distraction and fatigue combined with the set up of the room, the similarity of vaccines and organisational pressures to lead to the event

Did you identify these factors on your own or with input from other colleagues?

These factors were identified by the whole team during a SEA review meeting.

Lessons Learned

What lessons have been learned from the analysis of this event?

Cannot safely perform the same task for three hours. There are risks in how vaccines and medications are labelled. You need to be aware of situations where you may get distracted and try to eliminate the distraction before undertaking important tasks. For example, not allow relatives in the room or make it clear that you can only discuss vaccinations

What learning needs have been identified (at the individual, care team, and organisational levels, where appropriate)?

Individual – how to be more assertive with patients. Care team – set up of clinics including the positioning of vaccines. Organisation – safe ways to organise work – shorter clinics with breaks and variability are safer

Action Plan for Improvement

How have you minimised the chances of this even happening again? Vaccine storage has been changed. Lighting improved. Clinics made shorter with more variability. Patients are reminded when booking a vaccine appointment that the appointments are short and will not include opportunity to discuss other concerns.

Who is responsible for ensuring that these actions are implemented and how will these be monitored and sustained in practice? Storage changed by nurses. Practice manager arranging lighting upgrade – due in 14 days. New clinic structure agreed and will be tested in one week by the nursing team. Information to patients updated