What Are Significant Events?

 

The predecessor term to Significant Event Review was Critical Incident Analysis. This was a process to look at those negative outcomes which may have been triggered by negative events. The idea was based on the notion that if you could identify what were the causes which led to a bad undesirable outcome (for example, giving the wrong prescription to a patient) then you might be able to change things around to stop them happening in the future and thus improving patient safety and care.

 

The term was changed to significant event because sometimes you can get a really great outcome that was not anticipated. By reviewing the events which led to that "great" outcome might just be able to help you duplicate it more often.

 

So, significant events can be good or bad outcomes. Significant Event Review is a process to help you look at such events to identify factors which might need changing or promoting with the ultimate aim of improving patient safety and care. Promoting patient safety has other ramifications: it protects the practice, its staff and the doctors too.

In other words, everyone's a winner.

 

 

 

Okay, I'm Hooked, But How Do I Do It?

 

You mean the process? Oh right...

 

* Be insightful and be on the look out for any events which on reflection you think need exploring in more detail eg a prescription being sent to the wrong patient, a home visit that was overlooked and thus no visit recieved (even though it might have been for a minor thing) etc. What you're looking for are those events which although might not have resulted in a really bad outcome this time around, have the potential of being really bad in the future if they are simply ignored.

 

* Try and fix any problems that have resulted now.

 

* Then fill out methodically the "Significant Event Review Tool" in the downloads section of this page.

 

* Once you've done that, take the whole thing and present it to the rest of the team to see what needs to be done in the future to stop this happening in the first place. You'll get more opinions and ideas of ways in which you can change things if you take it back to the team. Then document the solution(s) the group has opted for.

 

* Recheck after a time period to make sure things are working smoothly or whether further fine tuning is necessary.

 

The format we require is the STRUCTURED review template in the downloads section above (the same as the form used by GPs in their appraisals). This has the advantage that you will be familiar with what is being expected of GPs before some of them have started to use it.

 

 

So, What Is the Actual Make Up Of A Significant Review?

 

You mean the content? May be this little diagram might help.