Patient Safety
Introduction
Abbreviation of “unit”—or not?.
Lamont T et al. BMJ 2010;341:bmj.c5269
©2010 by British Medical Journal Publishing Group
Is it important ?
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Study in England estimates that around
10% (900,000) patients admitted to NHS
hospitals have experienced an adverse
event (patient safety incident)
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50% could have been prevented
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33% led to moderate or greater disability
or death.
Vincent C et al BMJ 322:517-19
Seven steps to patient safety NPSA 2003
Harm in General Practice
from Patient Safety
Incidents
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UK Study of 10 GP Practices (2003)
940 errors in 2 weeks
75.6 per 1000 appointments
Between 3% and 9% very serious involving 4%
admission to hospital and 1% death
Today’s Agenda
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Intro
Alison’s presentation
Intro to SEA
Tea
Practical group work
Significant Event analysis
Do we need to do this ?
• QOF
• Appraisal
• Revalidation
Most errors are the result of
systems rather than individuals
and individual’s errors can be
prevented by good systems.
SEA’s can be the spotlight that
shows the changes in the
systems and processes that
need to be changed
Mike Pringle 2008
Seven stages of SEA
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Awareness and Prioritisation
Information Gathering
Facilitated team based meeting
SEA analysis
Agree implement and monitor change
Document it
Share and Review
Positive outcomes of SEA
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Celebration
No action
A learning need
A learning point
A conventional audit is required
Immediate change
A more in depth investigation required
Sharing and learning
SEA Exercise
• What happened
• Why did it happen
• What has been learned
• What has been changed or actioned