A Human Factors approach to significant event analysis for more meaningful improvement implementation to minimise the risks of the event happening again.
Enhanced SEA is a NES innovation (funded by the Health Foundation 2012 SHINE programme) which 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 staff involved.
Taking this approach will help individual clinicians and care teams to openly, honestly and objectively analyse patient safety incidents, particularly more difficult or sensitive safety cases, by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the significant event happened.
In this way, a more constructive approach to learning can take place and more meaningful improvement can be implemented to minimise the risks of the event happening again.
The following pages provide guidance on how to perform enhancedSEA and access the updated report format, new Guide Tools, a short e-learning module, and basic educational resources on human factors science and practice.
Download this short article on enhanced SEA:
*Please note: Although enhancedSEA was developed and tested with primary care teams the approach is also highly suitable for any health and social care setting.
These six modules explore how healthcare teams can apply human factors system thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.
Taking this approach will help individual clinicians and care teams to openly, honestly and objectively analyse patient safety incidents, particularly more difficult or sensitive safety cases, by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the significant event happened.
In this way, a more constructive approach to learning can take place and more meaningful improvement can be implemented to minimise the risks of the event happening again.
Significant Events can be any event thought significant by members of your team. They can also be called Learning Events as analysis should lead to learning and change for individuals and teams.
There are six modules. Each module describes a significant event set in a specific healthcare setting. Please select the significant event most relevant to your own care setting.
Please find below the final report which was submitted to The Health Foundation on enhancedSEA:
Health Foundation final report eSEA