Evaluating significant event analyses:

SUMMARY

Significant event analysis (SEA) may have the potential to minimise risk by enabling healthcare professionals to learn from good practice, as well as adverse events, errors and near misses. Analysis was carried out on SEA reports voluntarily submitted by GP principals for peer review assessment as part of their postgraduate education. SEA reports received were anonymised and sent externally to two randomly chosen GP assessors (from a group of 20), who independently reviewed each SEA using a criterion-referenced assessment schedule. A hundred and forty-six SEA were submitted to the department by 84 principals. Sixty-six (45%) highlighted clinically significant events, 56 (38%) administrative issues, and 24 (16%) a combination of both. Seventeen SEA (12%) directly involved verbal or written complaints made by patients or relatives. In total, 94 SEA reports (64%) were judged as satisfactory by the external GP assessors. GPs submitted a wide variety of significant event topics, ranging from communication issues to disease management. In the majority of cases, SEA submissions were not based on complaints made against the practice. However, there was a clear association between a satisfactory SEA peer review and the reported implementation of change as a result of the significant event. Further research is required into the SEA technique and the motivation behind the willingness of GPs to submit their own SEA for assessment by peer review.