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Significant event analysis. Maggie Eisner June 2009. Definition. An individual case in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) is analysed in a systematic and detailed way

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Significant event analysis


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significant event analysis

Significant event analysis

Maggie Eisner

June 2009

definition
Definition
  • An individual case in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient)
  • is analysed in a systematic and detailed way
  • to ascertain what can be learnt about the overall quality of care
  • and to indicate changes that might lead to future improvements.
  • It doesn’t work well if there is a ‘blame’ culture
sea in general practice
SEA in General Practice
  • Practices encouraged to have SEA meetings when an incident has occurred
  • GPs encouraged to include SEA in evidence for appraisal
  • Trainees encouraged to include SEA in EP log
  • SEA may be mandatory part of evidence for revalidation
  • SEA likely to be Deanery requirement for EP
  • But never mind all the people who’re demanding it of us - it’s a powerful and positive tool to make things better
an sea from your experience
An SEA from your experience
  • What happened?
  • Who was involved?
  • What feelings might they have had about the incident?
  • What about the relationships between the people involved?
  • What organisational systems were relevant to the incident?
  • What changes would you propose to reduce the risk of recurrence?
who there may be others
Who? (there may be others)
  • Person/people responsible for the event
  • Person/people who witnessed it
  • Person/people who reported it
  • Person/people who didn’t report it (although they knew or had an idea it had happened)
  • Person/people responsible for the team
  • Person/people affected by the event
  • Friends and relatives of person/people affected by the event
some of many possible feelings and relationships
Some of many possible feelings and relationships
  • Feelings – alarmed, sorry, guilty, angry, desperate, resentful, confused, indifferent, betrayed, embarrassed, upset, ambivalent, frightened, anxious, victimised, worried, unsupported, worthless, overlooked, belittled, misunderstood, self righteous, shocked, overwhelmed, sad, outraged, indignant, disappointed, despairing, bereft, irritated, impatient, weary, miserable, phlegmatic, discouraged, proud, satisfied, elated, relieved, flattered, glowing, affirmed, vindicated, energised, encouraged, excited, optimistic
  • Relationships - co-operative, competitive, collaborative, comradely, equal, unequal, hierarchical, respectful, contemptuous, trusting, mistrustful, bullying, obsequious, dismissive, familiar, unfamiliar, relaxed, tense, formal, informal, supportive, unsupportive, challenging, undermining
approaching sea
Approaching SEA
  • Standard questions
    • How could things have been different?
    • What can we learn from what happened?
    • What needs to change?
  • But it’s unlikely that we will learn anything if we don’t take account of people’s feelings, because the feelings get in the way of the learning. This is also true of the relationships between the people involved.
  • Feelings may need to be explored on 1:1 basis before and/or after any SEA meeting
  • SEA meeting chair needs group facilitation skills
systems
Systems
  • Personal organisation (to-do lists, notebooks, electronic reminders etc)
  • Communication
    • Spoken: doctor-patient, within team, handover
    • Written: medical records (paper, electronic), notice boards, correspondence, patient messages
    • Postal systems, telephone systems, electronic systems
    • Meetings
  • Access
    • Appointment systems
    • Telephone lines
  • Guidelines
    • Clinical
    • Procedural
  • Training
    • Induction
    • Refresher training
    • Cascading new information to team
write
Write
  • Write a first person (I) narrative of a SEA from the point of view of anyone involved in it except yourself
  • Include
    • What happened (as they see it)
    • Their relationships with other people involved
    • Their feelings about the incident
when your subjective writing is finished
When your subjective writing is finished
  • Make an objective note of exactly what happened
  • And what happened next
  • And the outcome
  • And – can you identify any ‘nodal points’ when a key decision was made which determined what happened next?
groups
Groups
  • Discuss the writing from one or more group members (good to read it out if you can)
  • Look at the systems relevant to the event
  • Discuss what might be changed, especially at the ‘nodal points’, to reduce the risk of recurrence
  • Discuss what would be needed to make the changes most likely to happen and be effective
  • Compare this with what actually happened