Transcript Headings 24pt Trebuchet

Pharmacy
Significant Event Analysis
Fiona McMillan
Lead Pharmacist Educational Development
April 2014
Educational Solutions for Workforce Development
Aim
To provide information about the
analysis of a Significant Event (SE)
‘To err is human, to cover up is unforgivable
and to fail to learn is inexcusable’’
Liam Donaldson 2004
Background
• SEA
embedded medical model
• Effective analysis allows reflection and learning within the team
•
Positive and negative events
•
Safe and effective medicines management needs systems to
ensure that patient safety is maintained.
• Sharing practice aids development of good practice.
What is a Significant Event?
“Any event thought by anyone in the health care team to be
significant in the care of patients or the conduct of the practice or
organisation.’
Pringle et al, 1995
Educational Solutions for Workforce Development
Pharmacy
Examples of Significant Events
Wrong drug
prescribed
Wrong drug
dispensed
Patient
complaints
IT issue
leading to
error
Drug
interaction not
noted
Medication
labelled
incorrectly
Lack of
Issues with
communication training
within
healthcare
team
What is the process for analysis and
receiving peer comments?
Update
Submit to NES
Feedback
Share again with peers
Complete
SEA
proforma
Discuss
at peer review +
include all involved
The Seven Stages of Significant Event
Analysis
• Stage 1: Awareness and prioritisation of
a significant event
Significant events should be prioritised for analysis based on their
consequences (actual or potential) for the quality and safety of patient
care.
• Stage 2: Information gathering
Collect information before the SEA meeting using both documentation
sources (PMR, SOPs, protocols etc) and from personal accounts
(patients, relatives, healthcare staff and individuals from other
agencies).
• Stage 3: The facilitated healthcare
team-based meeting
It is important to invite all relevant staff to the meeting. Learning needs
have to be identified and the meeting should be conducted in an open,
fair, honest and non-threatening atmosphere.
• Stage 4: Analysis of the Significant
Event
The Four What's: What happened? Why did it happen? What has been
learned? What has been changed or actioned?
• Stage 5: Agree, implement and monitor
change
This is vital to the success of the analysis of the Significant Event.
• Stage 6: Write it up
Written records should be kept using the NES Significant Event
Analysis documentation: http://www.nes.scot.nhs.uk/education-andtraining/by-discipline/pharmacy/pharmacists/cpd-audit-sea/significantevent-analysis-for-pharmacy-staff.aspx
• Stage 7: Report, share and review......
Stage 4
Questions in SEA form
What happened?
Give adequate detail to enable reviewers to understand the whole picture.
Why did it happen?
Explain reasons from your analysis by establishing the underlying reasons.
What have you learned?
Outline the learning needs identified and show that reflection and learning
has taken place.
What have you changed?
Will this prevent reoccurrence?
Example of a SEA Form and Peer
Feedback
NES will make your details anonymous before sending it to be peer reviewed
The possible consequences for the patient were
well described but does not mention the possible
impact the event will have on the staff
in the discussions...
It is vital that all patient and staff
details are omitted in this form
The feedback is sent back to the submitter as a letter
via email.
Benefits of SEA
Peer
reviewers
Peer review
Recording and
discussion with peers
Joint
Learning
+
improved patient
care
Individual
analysis
Why is SEA important?
• Analysis will help to reduce manage and
reduce risks.
• Reflection allows time to reflect on the event
and understand the reasons why it occurred.
• Reflection also fulfils some of the CPD
requirements.
• Identifies your own learning needs as well as
those in the healthcare team.