SIGNIFICANT EVENT ANALYSIS

Significant Event Analysis is another method of review that can help to resolve complex complaints.

Where there is a recognition that a specific area or team may benefit from this review process as part of an improvement journey, it should be considered.

The aim of the SEA is to allow teams to highlight both strengths and weaknesses in the care it provides. Improving the quality and safety of patient care is a key clinical governance priority and significant event analysis can have an important role to play in contributing to this aim, and should be embedded as a useful improvement tool.

Whilst similar to a directorate or desktop review, the main difference is the SEA should be conducted with staff that was involved in the care episode or event being analysed.

Below is a short guide that outlines how a SEA should be conducted:

Stage 1 – Awareness and prioritisation of a significant event

Within NHS Ayrshire & Arran, there is a well defined structure for commissioning Significant Adverse Event Reviews (SAER), and more recently, an Adverse Event Group has been formed to review all incident reports with a high consequence score. Where SEA will fit into this process will be considered by the AER group at a future meeting.

However, the use of directorate or desktop clinical reviews continue at service level and whilst there is a definitive need to review practice at the grassroots, it is difficult to evidence improvement or learning if a central register of the review processes are not held at the correct level. Carrying out the review is only the start of the process and failure to evidence learning or improvement as a result remains a significant organisational risk.

Whilst work continues on the processes to ensure a central record of all reviews is developed to guarantee follow up of identified learning needs, we need to recognise the role SEA can play in this transition, and how it can be led and reported at a service level, before recommendations are shared and learning occurs.

In the context of SEA in relation to complaints, the ownership of improvement will remain with the service, with support from the Improvement Lead for Customer Care – this will help ensure we close the learning loop and can demonstrate sustainable improvement.

Where clinical staff feel a significant event has occurred, an incident report should be submitted and an SBAR prepared for review by the Chairs of the AER group. At this stage, a decision will be made as to the level of review and communicated to the right people.

26 | P a g e Stage 2 – Information gathering

Once the SEA has been commissioned, the lead facilitator will be identified (usually the manager of the clinical service). They are then responsible for ensuring that the correct level of evidence is gathered. At this stage, the Improvement Lead for Customer Care can be contacted for assistance or direction.

The facilitator should collect and collate as much factual information as possible from;

• Staff statements

• Written records

• Other healthcare records

• Complaint file timeline if appropriate

• In preparation for the meeting, a clinical timeline should be produced using the format shown in Appendix I – the clinical timeline should be carried out by the Lead facilitator or someone designated by them

In order that learning can be shared and future incidents avoided, it is important that the SEA is conducted in a timely manner. If the SEA is an SPSO recommendation, it usually is allocated a 2 month completion date and the timeline has been developed with this in mind

STAGE TO BE COMPLETED IN

SEA commissioned and Lead & Review

Team identified (Stage 1) Within 10 working days of commission Information Gathering and Completion of

Timeline by Lead Facilitator with QI Lead

support (Stage 2) Within 21 working days from commission Team Meeting and Analysis (Stage 3, 4 &

5) Team should meet within 14 working days of Stage 2

Minutes should be recorded and agreement reached on how outcome should be shared, implemented and monitored

Produce Report (Stage 6) The report should be produced within 21 working days of team meeting

Report, Share and Review (Stage 7) Draft report to be shared with team and service.

Sent to appropriate governance group for approval Final report produced and Actions

implemented

Report and any associated Learning Notes should be shared with appropriate service personnel as identified by AER Group/and or relevant governance structure and any actions for improvement should be implemented and monitored by QI Lead

Stage 3 – The Facilitation based team meeting

The team should appoint a facilitator who will structure the meeting, maintain basic ground rules and help with the analysis of the event. Reinforce the educational spirit of the SEA and ensure opinions are respected and individuals are not blamed.

Minutes of the meeting should be taken and action points noted. These should be sent to all staff involved in the SEA.

An effective SEA should include detailed discussion of each event, demonstration of insightful analysis, the identification of learning needs and agreement on any action to be taken.

27 | P a g e Stage 4 – Analysis of the significant event

This can be guided by answering these 4 questions;

• What happened?

• Why did it happen?

• What has been learned?

• What has been changed or actioned?

Possible outcomes may include;

• No action required

• Identification of a learning need

• A conventional audit is required

• Immediate action is required

• Further investigation is required

• Learning must be shared

Stage 5 – Agree, implement and monitor change

Any agreed action should be implemented by staff designated by the SEA team to coordinate and monitor the change

Progress with the implementation of change should always be monitored by placing it on the agenda at the appropriate team meetings - this is vital to the SEA process as we need to evidence that measures have been taken to prevent any further adverse events of the same nature. A critical question to ask as a result of the SEA is “What is the chance of this happening again?”

Stage 6 – Write it up

It is important to keep a comprehensive, anonymised written record of the SEA, as external bodies may require to evidence that the SEA was undertaken to a satisfactory standard. The SEA is a written report of how well the significant event was analysed.

The SEA should be written up in SBAR format using the template (see Useful documents).

Stage 7 – Report, share and review

Reporting when things go wrong is essential. The SEA should be shared through the organisations AER group, and the relevant governance committees.

28 | P a g e WHICH REVIEW SHOULD WE USE?

In order to decide the best process to use, it’s important to consider what the complainant requires, and how best potential improvements can be identified and actioned.

As SEA involves the team that is involved in the complaint, there is already a background understanding of the issues raised and the potential barriers to learning and improvement. This process is best used where it has already been established that aspects of the complaint will be upheld. Whereas, a directorate review is a more independent review and is ideally suited for use where complaint resolution has not been achieved and/or the complainant has identified failures.