Significant Event Audit in UK General Practice

Significant Event Audit /Analysis (SEA)
In UK General Practice
“…Individual cases in which there has been a significant occurrence (not
necessarily involving an undesirable outcome for the patient) are analysed in
a systematic and detailed way to ascertain what can be learnt from the overall
quality of care and to indicate changes that might lead to future
improvements” (1)
“At a regular inter-professional team meeting, team members focus on
particular incidents considered significant, to learn and improve from.” (2)
Some Background
Case review is one of the oldest principles underlying the development of
SEA has been around formally in General Practice since 1980s as both a
Quality Assurance and Educational tool. It developed out of conventional
audit, Random and Problem Case analysis techniques and with patient safety
very much at its heart
SEA is now part of GPs new contract, GP Appraisal and Revalidation,
Training of GP registrars and Clinical Governance as well as Practice
Accreditation (PA) and Quality PA by the Royal College of General
How it is done – an example
Steps to be Taken in The Analysis Of a Significant Event (1)
1. Consider the events to be audited
2. Collect data and record facts
3. Hold a meeting to discuss the events the meeting should cover some
or all of the following points
 Immediate management of the case
 Preventative care options
 Follow up of the case
 Implications for the family /community
 Interface issues
 Team issues action to be taken /policy decisions to be made
 Follow up arrangements
4. Documentation
Documenting - should always include data and discussion in these areas (3)
What happened
Why did it happen
What has been learned
What has been changed
The Pros and Cons of SEA
Strengths of SEA (1)
 Outcomes focused
 High emotional appeal
 Commitment to change
 Practical and relevant issues
 Less preparation
 Less reliant on written records
 Feedback immediate, verbal from known peers
 Builds trust and team working
 Raises interface and team issues
Potential drawbacks (1)
 May be superficial
 May be threatening
 Emotionally demanding
 May require training to do well
 Can expose team/interface issues that are difficult to resolve
 Requires discipline in discussions and clear end points.
 Group dynamics
 Medico-legal
And importantly - up to now the reporting and learning only occurs at practice
level - There are no national reporting systems for General Practice
The English National Patient Safety Agency is however embarking on an
initiative to encourage a structured method of sharing the learning from SEA
within primary care organisations and nationally in 2005-6 (4)
SEA in General Practice is not  The right place for dealing with serious incidents or
 The right place for dealing with issues of poor performance.
 A one off meeting to discuss an adverse event e.g. critical incident
 A critical incident case study.
 About individual blame
 A patient notes audit
 Grand rounds
SEA in General practice is
 About improving systems
 About quality improvement
 About identifying educational needs
 About shared learning
 About mutual trust
 About team building
1.Pringle M et al. Significant event auditing. Occasional Paper 70. Exeter:
RCGP, 1995.
2.Stead J. Sweeney G. Significant event audit-a focus for clinical governance.
Kingsham Press;2001.
3.The Revalidation Toolkit RCGP (Scotland) website
4. Scobie, S, Thompson, R. ‘Building a Memory – preventing harm, reducing
risks, and improving patient safety’ National Patient Safety Agency, July 2005
See also NPSA website
Sue Tracey August 05
Dept of General Practice & Primary Care
University of Aberdeen