Significant Event Audit

Significant Event Audit - also called Significant Event Review or Analysis - is an increasingly routine part of general practice. It is a technique to reflect on and learn from individual cases to improve quality of care overall.

Significant event audits should form part of your individual and practice based learning and quality improvement.

Whether clinical, administrative or organisational, the significant event analysis process should enable the practice to answer the following questions:

  • What happened and why?
  • How could things have been different
  • What can we learn from what happened?
  • What needs to change?

A further worthwhile question is:

  • What was the impact on those involved (patient, carer, family, GP, practice)?

SEA team discussions should be a routine part of your practices quality improvement and clinical governance and is an opportunity for the team to:

  • discuss each stage in detail
  • identify any learning needs
  • identify actions to be taken and changes to be made and agree how these will be processed.

Early Diagnosis of Cancer and Quality Improvement Pilot 2015/2016

In 2015/2016 the RCGP undertook a pilot project in Early Diagnosis of Cancer and Quality Improvement using Significant Event Analysis. This builds on the guidance and tools located on this webpage.

Further information is available here.

Guidance

The key functions and expertise for patient safety developed the National Patient Safety Agency (NPSA) have been transferred to NHS England. The NPSA have produced guidance to support primary care teams in conducting effective significant event audits with the aim of improving care for all patients. The guidance gives primary care teams a tool to develop a structured significant event audit process and demonstrates what can be achieved.

The development of this Significant Event Audit guidance was jointly undertaken by NHS Education for Scotland and the National Patient Safety Agency, with support from the Royal College of General Practitioners and Quality Improvement Scotland.

NPSA SEA Guide [PDF]

NPSA SEA Quick Guide [PDF]

Enhanced Significant Event Analysis

Enhanced Significant Event Analysis is a further improvement to the existing structures. In an NHS Education for Scotland pilot funded by the Health Foundation Shine programme, a human factors approach was taken. It considers contributory factors and their interactions to an event under the concepts of people factors, activity factors and environment factors. Further details on this study can be found at the link below.

Enhanced SEA

Revalidation

Significant event audit is an important part of revalidation. A GP's revalidation portfolio will be expected to contain an analysis of at least ten significant events. At least two SEAs (or case reviews) should be included in your annual appraisal.

RCGP guidance to the revalidation of General Practitioners. The guidance on SEA is contained in pages 34- 37.

Cancer Significant Event Audit pilot (2012 - 2013)

The Cancer Significant Event Audit (SEA) Peer Review Pilot was the joint initiative of the RCGP, the National Cancer Action Team (NCAT) and Macmillan Cancer Support.

The one year pilot offered anonymised external peer assessment of SEAs of cancer diagnosis. 13 of the 28 NCAT networks participated, with a total of 95 SEAs received.

The pilot sought to:

  • encourage reflection and learning around cancer diagnosis
  • provide practices with an opportunity to develop their SEA technique
  • assess the longer-term impact SEAs can have on practice.

Pilot report and resources

Final report: Cancer SEA Peer Review Pilot Final Report [PDF]

Recommendations: Cancer SEA Peer Review Pilot Recommendations [PDF]

Templates: in the course of the pilot, the templates used became more detailed, reflecting our learning about the content required of an SEA undertaken to a good standard.

Annotated SEAs: Example SEA reports annotated with reviewer feedback to compare your SEA technique against:

 

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