Addressing the emotional barriers hindering patient safety investigations in primary care NHS Education for Scotland

The NHS Education for Scotland project aimed to minimise harm and involve patients in safety-related concerns, through the use of significant event analysis (SEA) - a collective learning technique for investigating patient safety incidents in primary care. The initiative took a human factors, systems-based approach to SEA to:

• reduce the emotional barriers to acknowledging safety incidents
• enhance empathy
• develop more meaningful event analyses and action for improvement.

The project team developed an SEA toolkit incorporating a desk-based personal booklet, an illustrated desk pad, a revised report format and an e-learning module.

Who was involved

NHS Education for Scotland's primary care educational network acted as the project steering group and oversaw the design, development, implementation, and testing of the toolkit with sample groups of dentists, GPs, pharmacists, optometrists and clinical psychologists across Scotland.

The project team included the lead for safety and improvement and the national GP director, along with experts in education for general practice and dentistry, clinical psychology, management and nursing within general practice, optometry, pharmacy and accountancy.

Dalhousie University supported the team with expertise in feedback and continuing professional development.

Impact

SEAs were submitted by 102 participants, with 88 completing the post-study questionnaire and 21 providing feedback in an interview.

The findings suggested that the intervention improved clinicians' understanding of human factors practice, how to lead an event analysis and emotional responses to incidents.

Challenges

The team experienced challenges when engaging with groups who had no previous experience of SEA.

Feedback revealed usability concerns with the new SEA report format and the e-learning module, which the team went on to address.

Supporting dissemination

This project was given further support through a Spreading Improvement grant to help disseminate learning and maximise the impact of the approach across the health service.

Funding was used to refine and promote the tools, then evaluate their usability and impact based on human factors principles. The project also promoted and disseminated the intervention nationally and successfully engaged key national stakeholders such as the Royal College of General Practitioners.

Resources

Take a look at a variety of eSEA resources.