Maggie EisnerJune 2009

An individual case in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient)

is analysed in a systematic and detailed way to ascertain what can be learnt about the

overall quality of care and to indicate changes that might lead to

future improvements. It doesn’t work well if there is a ‘blame’

culture

Practices encouraged to have SEA meetings when an incident has occurred

GPs encouraged to include SEA in evidence for appraisal

Trainees encouraged to include SEA in EP log SEA may be mandatory part of evidence for

revalidation SEA likely to be Deanery requirement for EP But never mind all the people who’re

demanding it of us - it’s a powerful and positive tool to make things better

What happened? Who was involved? What feelings might they have had about

the incident? What about the relationships between

the people involved? What organisational systems were

relevant to the incident? What changes would you propose to

reduce the risk of recurrence?

Person/people responsible for the event Person/people who witnessed it Person/people who reported it Person/people who didn’t report it

(although they knew or had an idea it had happened)

Person/people responsible for the team Person/people affected by the event Friends and relatives of person/people

affected by the event

Feelings – alarmed, sorry, guilty, angry, desperate, resentful, confused, indifferent, betrayed, embarrassed, upset, ambivalent, frightened, anxious, victimised, worried, unsupported, worthless, overlooked, belittled, misunderstood, self righteous, shocked, overwhelmed, sad, outraged, indignant, disappointed, despairing, bereft, irritated, impatient, weary, miserable, phlegmatic, discouraged, proud, satisfied, elated, relieved, flattered, glowing, affirmed, vindicated, energised, encouraged, excited, optimistic

Relationships - co-operative, competitive, collaborative, comradely, equal, unequal, hierarchical, respectful, contemptuous, trusting, mistrustful, bullying, obsequious, dismissive, familiar, unfamiliar, relaxed, tense, formal, informal, supportive, unsupportive, challenging, undermining

Standard questions How could things have been different? What can we learn from what happened? What needs to change?

But it’s unlikely that we will learn anything if we don’t take account of people’s feelings, because the feelings get in the way of the learning. This is also true of the relationships between the people involved.

Feelings may need to be explored on 1:1 basis before and/or after any SEA meeting

SEA meeting chair needs group facilitation skills

Personal organisation (to-do lists, notebooks, electronic reminders etc)

Communication Spoken: doctor-patient, within team, handover Written: medical records (paper, electronic), notice boards,

correspondence, patient messages Postal systems, telephone systems, electronic systems Meetings

Access Appointment systems Telephone lines

Guidelines Clinical Procedural

Training Induction Refresher training Cascading new information to team

Write a first person (I) narrative of a SEA from the point of view of anyone involved in it except yourself

Include What happened (as they see it) Their relationships with other people involved Their feelings about the incident

Make an objective note of exactly what happened

And what happened next And the outcome And – can you identify any ‘nodal points’

when a key decision was made which determined what happened next?

Discuss the writing from one or more group members (good to read it out if you can)

Look at the systems relevant to the event Discuss what might be changed, especially

at the ‘nodal points’, to reduce the risk of recurrence

Discuss what would be needed to make the changes most likely to happen and be effective

Compare this with what actually happened