Significant event analysis (SEA) is a collective learning technique used to investigate patient safety incidents (circumstances where a patient was or could have been harmed) and other quality of care issues.
About the project
The project team at NHS Education for Scotland (NES) had more than 15 years’ experience of working on SEA in primary care. They identified limitations in how SEA was being used and set about investigating and developing a new approach during a project funded by our SHINE 2012 programme.
The new approach is based on human factors principles. Human factors is a broad scientific discipline which seeks to understand and improve the ‘fit’ between people and their working environment to ensure a safer, more productive and efficient workplace. It is commonly used in areas such as aviation and engineering where safety is critical. Three interacting system elements (people, activity, and environment) are crucial to understanding safety in a health care environment. Using these principles helps teams to move away from blame – significant events are rarely simply the result of one person’s actions or inactions.
Applying a structured framework enables safety incidents to be analysed constructively. However, there can also be emotional barriers preventing deep engagement with the SEA process. People may believe they are solely responsible for events, and feel shame, guilt, or be afraid of speaking up.
The NES project looked at ways of supporting people in primary care teams to improve how SEA is performed.
Paul Bowie, Programme Director (Safety and Improvement) at NES says, ‘The very act of attempting to take a systems approach should reduce the blame factor because it puts the focus more broadly on the system and takes it away from the individual or the individuals involved.’
Supporting teams to move away from blame
The resulting approach, named ‘enhanced SEA’, acknowledges the complexities of health care systems.
The project gives an example of a health visitor training to administer childhood vaccinations. The health visitor starts to work under supervision. A three-month old girl attends for a booster vaccination appointment at a busy clinic. The MMR and DTP/Hib vaccinations are on the same table. The health visitor accidentally picks up the wrong vial while answering the mother’s questions and administers MMR rather than the required DTP/Hib vaccination. The child is assessed on several occasions and does not suffer any harm, but parents and staff are distressed by the event.
Several interacting factors can be identified using the enhanced SEA approach: people (eg the health visitor felt under pressure because of the busy clinic), activity (eg a high volume safety task was being performed which required effective checking) and environment (eg the room was cramped with only one table for all vaccines; efficiency savings meant different age groups attend a combined vaccination clinic). Reflecting on these factors enables a coherent action plan to be put in place to reduce the risk of a repeat incident.
Paul says, ‘There’s more at play here than what happened on the day. In the vast majority of cases there’s a system perspective to be looked at, and there’s learning across that system. Our approach also considers the role of the clinicians or the team members involved, and managing the possible emotional impacts on them.’
The approach encourages teams to move away from blame, or from searching for a ‘root cause’, and instead to identify and prioritise system-wide learning and improvements that can be made to prevent future events.
Four tools to help apply enhanced SEA
The project developed a framework and then a series of practical tools, which aim to help people working in primary care to apply the approach.
1. E-learning module
This short ‘read and click’ e-learning module is available as a PDF from the Quality Improvement Hub. It explains and illustrates the principles which underpin the enhanced SEA approach, including sections on: Basic error theory; Human factors principles; Taking a systems-centred approach; and the Enhanced SEA method.
2. Enhanced SEA booklet
The enhanced SEA booklet (PDF), developed by the project team, gives a clear, readable overview of the approach, including the basics of human factors theory and an example story. It aims to help individuals reflect on the potential emotional impacts of a significant event by using these principles to gain a clearer understanding of all of the contributory factors involved.
In addition to individual reflection, it’s important that teams reflect together on events and analysis. Each sheet of this enhanced SEA deskpad (PDF) contains instructions and prompts to help guide a team in taking this approach to event analysis, and to take notes on what was agreed.
4. Reporting template
The project team also designed and developed a new report format (PDF) for writing up SEAs, which accommodates this approach. This format is recommended for GP specialty training and medical appraisal, as well as for practice manager and nurse vocational training and appraisal. It is also being used in community pharmacy and dental practice in Scotland.
Embedding the enhanced SEA approach
With its educational role, NES has been able to disseminate enhanced SEA through existing networks in GP training, nursing training, pharmacy, and throughout primary care. Paul also describes an unexpected outcome of the project, ‘we put together a multidisciplinary group of primary care lead educators to develop and test the enhanced SEA tool. That group still exists and is now considering a whole range of other safety and improvement topics and initiatives. An entire network, a community of practice has been borne out of this project.’