Transcript What is a Significant Event?

Pharmacy
Significant Event Analysis
Fiona McMillan
Lead Pharmacist Educational Development
Educational Solutions for Workforce Development
Aim
To advise on development of a process for the analysis
of Significant Events to promote learning and reflection
within your team
‘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
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
What have you learned?
Can be a list
What have you changed?
Will this prevent reoccurrence
Benefits of SEA
Peer
reviewers
Joint
Learning
+
improved patient
care
Peer review
Recording and
discussion with peers
Individual
analysis
How could you integrate this into your practice?
•What benefits do you see?
•What are your next steps?
Educational Solutions for Workforce Development
Pharmacy