Enhanced Significant Event Analysis in General Practice

Adam HayThursday 2nd October 2014

S E A

Why do an Enhanced SEA?

• Necessary part of GPST training• SEA has developed from high risk organisation• We make mistakes every day – why not learn

from them?– 9 out of 10 medical consultation are based in

primary care– 1-2% of these are estimated to have some level of

error occurring

Why change to the Enhanced SEA?

Why change to the Enhanced SEA?

• Criticisms of the old SEA– Lead to a superficial description of the process– No active action often taken– SEA were often discussed informally– SEA choice often “selective”

• Enhanced SEA aims to avoid all this and– Encourage professional learning– Improve patient care– Discourage blame culture

Blame Culture & Traditional SEA

• A feeling of blame post-SEA could occur due to:– Hindsight bias– The illusion of free will– Fundamental attribution bias– Just world hypothesis

Benefits of doing Enhanced SEA

• Enhanced SEA during GPST training is intended to aid– Understanding reasons for error occurring– Improve the safety culture– Enhance teamwork and communication– Improve the healthcare system– Attempt to aid predicting what might go wrong in

the future

How to choose a significant event

How to choose a significant event

• What makes an event significant?– “Any event thought by anyone in the team to be

significant in the care of patients or the conduct of the practice”

Pringle et al 1995

• What type of events are often seen?– Near miss– Adverse event– Error

Types of Error

• Active error or passive error

• Can be:– Slip– Lapse– Mistake– Violation

How to record your Enhanced SEA• Useful to complete the short e-learning module from NES

– http://www.nes.scot.nhs.uk/media/2408590/enhanced_significant_event_analysis_module_-_updated.pdf

– Or search “Enhanced SEA” on NES website

• You are advised to use the template available from NES websitehttp://www.nes.scot.nhs.uk/Navigate:>Education and training>>By theme / initiative>>>Patient Safety and Clinical Skills>>>>Enhanced Significant Event Analysis>>>>>The Guide Tools & Report Format

Steps in the Enhanced SEA Report

Section One• Title page

• Describe what happened

• The impact or potential impact

Steps in the Enhanced SEA Report

Section Two• Human and System factors

• How these factors combined to make the event happen

• Did you identify these factors by yourself or with the help of others

Human Factors

• “concerns understanding interactions among humans and other elements of a system…”

• “also concerns applying theory, principles, data and methods..in order to optimise human well-being and overall system performance”

(International Ergonomics Association)

Types of Human Factors to consider

• People Factors– E.g. patients, interactions between staff– Directly and possibly indirectly involved

• Activity Factors– E.g. task complexity, lack of protocol or guidance

• Environment Factors– E.g. physical environment, practice culture,

time/work load pressure, lighting, noise etc

Case Example for Human FactorsA Receptionist asked the duty GP to sign a repeat prescription forAmitriptyline for a patient waiting at the desk.

The GP noticed the dose of Amitriptyline appeared incorrect and checked the patient’s medical record. The GP discovered that Amisulpride, rather than Amitryptiline, should have been prescribed.

She amended the prescription, explained the error to the patient, andapologised.

Fortunately, the patient had not suffered any complications from thewrong drug (and dose) and had not suffered a psychoticexacerbation.

Possible Human and System Factors

PEOPLE An administrative team member had entered the prescription incorrectly a few months before. Amitriptyline is prescribed often, and has several indications, including chronic pain and irritable bowel syndrome. Amisulpride is an antipsychotic drug and is very rarely prescribed.Assumed from experience and deciphering of written note that is must be Amitriptyline.Lacked sufficient clinical knowledge to realise a potential patient safety issueA GP had signed the initial, wrong prescription.Patient expectation of quick service.

ACTIVTY The initial request for Amisulpride was a handwritten note and mostly illegible.GPs often sign batches of prescriptions, without always checking for accuracy.Flexible working to attempt satisfy patient need on the day.

ENVIRONMENTTime and workload pressuresDistractions and noisy environmentPossible staff training on awareness of high risk medicationsAvailability of handwritten prescriptionsSafety system design issue with repeat prescribing signing by GPs

Steps in the Enhanced SEA Report

Section Three• What lessons have been learned?

• What learning needs have you identified?

Steps in the Enhanced SEA Report

Section Four• How have you minimised the chances of this

event happening again?

• Who is responsible for ensuring this?

Steps in the Enhanced SEA Report

Step Five• Submit your Enhanced SEA for peer review– June.morrison@nes.scot.nhs.uk

Short Exercise on Human Factors

• Work in groups• Consider– What was the impact?– Why did it happen?• Consider in terms of Human Factors and System Factorsi.e. People, Activity, Environment

– What could be learnt from it?– What changes could be implemented?

Case Study 1

Mr X’s son made an appointment with Dr G to complain about the care of his father. Mr X’s father had attended Dr G seven days previously, feeling unwell, and Dr G had taken a blood test, and told the patient he would phone him with the result. Four days after seeing Dr G, Mr X had been admitted to hospital, where a blood test demonstrated severe anaemia. The hospital staff said that they could not find the original blood test taken by Dr G on the hospital computer. The son felt that action should have been taken sooner and the blood result acted upon.Unfortunately there was no record of the blood test having gone to the laboratory or the result having been received by the practice.

Case Study 2

Mr T arrives at the reception desk and begins to shout at the receptionist demanding to see the doctor because his prescription had been changed. Mr T had taken his usual prescription to the pharmacist who had dispensed a generic tablet instead of the usual branded tablet. When Mr T queried this, the pharmacist had told him that the practice had changed the tablets as they were ‘cheaper’. Mr T was irate and threw the tablets at the receptionist narrowly missing her.

End.Any questions?