Significant Event Analysis Research Articles

Learning from new colorectal cancers: a qualitative synthesis of significant event reports.

Colorectal cancer is the second leading cause of cancer-related mortality in the UK and a significant contributor to morbidity and mortality worldwide. Early diagnosis provides opportunities for intervention and improved survival. Significant event analysis (SEA) is a well-established quality improvement method for learning from new cancer diagnoses. To provide additional insights into diagnostic processes for colorectal cancer and to identify areas for improvement in patient care pathways. Fifty-three general practices across Pennine Lancashire, England, submitted one or more SEA reports as part of an incentivised scheme. A standardised data collection form was used to collate learning points and recommendations for improvements. In total, 161 reports were analysed using an inductive framework analysis approach. There was an overarching theme of building vigilance and collaboration between and within general practices and secondary care. The following four main sub-themes were also identified: education; individualised and flexible care; ownership and continuity; and communication. These findings provide additional insights into colorectal cancer pathways from a primary care perspective. Practices should be supported in developing protocols for assessment and follow-up of patients with varying presentations. Screening and access to investigations are paramount for improving early diagnosis; however, a flexible diagnostic approach is required according to the individual circumstances of each patient.

Final-year medical students' reflections on types of significant events in primary care.

Adverse events are considered a universal challenge and a burden in the provision of healthcare. For that reason, significant event analysis (SEA) is a critical undertaking in primary health care (PHC), particularly in South Africa where 84% of the population relies on the public health system for their care. The study aimed to describe the types of perceived significant events medical students experienced during an integrated primary care block placement. Eighteen PHC settings included clinics, community health centres and district hospitals across three provinces in Gauteng, Mpumalanga and the North West. Using a qualitative descriptive design with purposeful sampling and maximum variation, structured reflection reports were retrieved from logbooks of final-year medical students studying at a South African university in 2014. Conventional content analysis was used to record the relevant facets of secondary data from 124 logbooks that contained a recording of a significant event using MAXQDA software version 2020.4. An iterative process revealed three major themes of significant events that were prevalent in PHC settings. These comprised medication and prescription errors, diagnostic errors and suboptimal patient management. Significant event analysis became a critical quality improvement reflective learning tool. Logbooks offered an opportunity for medical students to explore significant events as a strategic way towards addressing quality and safe practices in PHC settings.Contribution:This study demonstrated medical students' ability to identify incidents in the care of patients using the SEA approach and their role in assessing patient safety issues in PHC settings.

In the midst of a pandemic, significant event analysis may protect the well-being of healthcare professionals

In the midst of a pandemic, significant event analysis may protect the well-being of healthcare professionals

SEA change – the use of significant event analysis in primary care teaching

ABSTRACT Background Significant event analysis (SEA) is a concept familiar to clinicians as a means to facilitate group learning. Our academic primary care teaching team recognised that often significant educational events are not afforded the same formal evaluation and reflection. We designed a proforma for the analysis of events in our setting and scheduled regular meetings to discuss those events raised. In this paper we describe a year long trial of our novel Significant Event Analysis for Education (SEAFE). Evaluation The pilot was evaluated using an online questionnaire. Discussion Over the 12 months of the pilot 19 SEAFEs raised and discussed with a wide range of subjects covered. 78% of our team felt that the use of SEAFEs had imporved their practice as clinical academics and 89% supported the continued use of SEAFE. Conclusion We have demontrated that SEA can be used in an academic primary care educational setting to bring about group learning and improvement in academic practice. We are planning to continue the use of SEAFE within our team with plans to try to pilot this outside of a primary care setting soon.

Trainee engagement with reflection in online portfolios: A qualitative study highlighting the impact of the Bawa-Garba case on professional development

Background Reflection is an essential tool for postgraduate medical training, yet fear of exposing incompetence is a known barrier for engagement with reflection. In the UK, this fear may have been amplified by the case of Dr Bawa-Garba, whose reflective e-portfolio entries informed a General Medical Council investigation resulting in the loss of her licence to practice. Aim To identify themes GP trainees commonly explore in e-portfolio entries, and whether their reflective e-portfolio entries have changed following the Bawa-Garba case. Method A phenomenological approach was applied. Semi-structured interviews continued to data saturation in a purposive sample of trainees (7) and trainers (4) recruited from a South Yorkshire GP training scheme. Transcript data were assigned to a coding framework with iterative thematic analysis. Results Dominant emergent themes were ‘difficulty’ and ‘challenge’. All trainees described reluctance to submit significant event analyses (SEAs) on mistakes and near misses for fear of jeopardising their careers. International medical graduates were disproportionately affected by the challenges reflection posed. Conclusion Following the Bawa-Garba case, trainees are disengaging with SEAs to reduce the risk of self-incrimination. Further guidance with which trainees can navigate their reflective e-portfolios is required to retain the value of reflection as a tool for professional development.

The importance of significant event analysis

Significant event analysis (SEA) is a structured quality improvement activity that is well established in general practice. Participation in SEA prompts primary care teams to reflect on their clinical reasoning, to highlight exemplary care, and to identify any potential improvements in both practice and wider healthcare systems. This article provides an overview of the SEA process and the events surrounding a SEA meeting. Cancer care examples are used to demonstrate how SEA can be used to enhance team-based learning and improve future patient care.

Death audits and reviews for reducing maternal, perinatal and child mortality.

© 2018 The Cochrane Collaboration. This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the impact and cost-effectiveness of different types of death review in reducing maternal, perinatal and child mortality.

Cancer care at a crossroads: Realising the potential in primary care in New Zealand

The recently published New Zealand Cancer Action Plan 2019–2029 identifies important roles for primary care including early detection, management of chronic conditions and comorbidities, and supporting people to live well with and beyond cancer. Presentations for cancer are different in primary than secondary care, and primary specific knowledge and skills are required. Education focused on clinical practice needs to be backed up by primary care research. Opportunities to improve cancer outcomes include using safety netting to manage non-specific symptoms, providing post-diagnosis health assessments and co-morbidity management and including cancer significant event analyses in peer review.

Practice of Significant Event Analysis for Junior Residents at Kin-ikyo Chuo Hospital

Practice of Significant Event Analysis for Junior Residents at Kin-ikyo Chuo Hospital

Optical pupillometry in traumatic brain injury: neurological pupil index and its relationship with intracranial pressure through significant event analysis

ABSTRACTPrimary Objective: Treatment paradigms for traumatic brain injury (TBI) rely on invasive monitoring of intracranial pressure (ICP) for planning intervention. Optical pupillometry is a non-invasive, objective monitoring method, measuring parameters of pupillary response and displaying a scalar value – a neurological pupil index (NPi). An impaired response on NPi has been tentatively correlated with ICP, through analysis of mean/peak NPi and ICP readings. We sought to evaluate this relationship more closely.Research Design: Prospective observational.Methods and Procedures: We obtained hourly pupillometry readings, alongside ICP values, from 40 patients with TBI requiring invasive ICP monitoring. Significant events were identified for analysis based on the significant aberration of ICP or NPi.Main Outcomes and Results: On average, individuals experienced a few significant events. There was a weak relationship between ICP events and a preceding NPi event. The results show that there is a weak but statistically insignificant relationship between NPi and ICP, where reduced pupil reactivity may indicate a raised ICP. The strength of this trend appears to diminish post-decompressive surgery.Conclusions: Whilst pupillometry may not be a reliable surrogate marker for ICP, NPi may still prove to be a useful tool in a multimodal prognostic assessment of the patient with acute brain injury.

Dental trainees reflect more critically on negative experiences: portfolio analysis using a pragmatic approach and a rubric in Japan

BackgroundDental trainees have various clinical experiences during their internships and they grow by experiencing success and failure. When looking back on an event, it is not apparent which experiences result in more critical reflection. Therefore, we qualitatively analyzed the portfolios of dental trainees using Significant Event Analysis to investigate their depth of reflection.MethodsWe asked all Hiroshima University Hospital dental trainees who completed a 1-year training program between 2010 and 2016 to describe their most memorable event from the past year. We coded the text using a qualitative analysis method. Then, we classified the responses as positive or negative events. We evaluated the depth of reflection following a pragmatic approach to categorizing reflective material (Sandars method) and a reflective ability rubric and user guide (O’Sullivan method) and compared these results. The evaluation was performed separately by two researchers and a good rate of agreement was confirmed by the weighted kappa statistic. Comparison of the depth of reflection was performed by the Mann-Whitney U test.ResultsThe assessments of the positive event group and negative event group were compared with the respective evaluation criteria of the Sandars and O’Sullivan methods, and reflection was found to be deeper in the negative event group. The Mann-Whitney U test revealed a significant difference (p < 0.05) in the median values of the two groups for both methods.ConclusionsBoth positive and negative experiences are important for dental practitioners to grow, but negative experiences are associated with critical reflections. In promoting the growth of training dentists, it is considered important to encourage deep reflections on positive experiences that are likely to be shallow.

Effective significant event analysis

Significant event analysis is commonly used to enhance safety in general practice and aid learning and improvement. Kate Taylor looks at what can make the process more streamlined in general practice

A Significant Event Analysis of the Case of Unsuccessful Tracheal Extubation：Reflection from the Perspective of Medical Education

A Significant Event Analysis of the Case of Unsuccessful Tracheal Extubation：Reflection from the Perspective of Medical Education

Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care.

Introduction:Significant event analysis (SEA) is well established in many primary care settings but can be poorly implemented. Reasons include the emotional impact on clinicians and limited knowledge of systems thinking in establishing why events happen and formulating improvements. To enhance SEA effectiveness, we developed and tested “guiding tools” based on human factors principles.Methods:Mixed-methods development of guiding tools (Personal Booklet—to help with emotional demands and apply a human factors analysis at the individual level; Desk Pad—to guide a team-based systems analysis; and a written Report Format) by a multiprofessional “expert” group and testing with Scottish primary care practitioners who submitted completed enhanced SEA reports. Evaluation data were collected through questionnaire, telephone interviews, and thematic analysis of SEA reports.Results:Overall, 149/240 care practitioners tested the guiding tools and submitted completed SEA reports (62.1%). Reported understanding of how to undertake SEA improved postintervention (P < .001), while most agreed that the Personal Booklet was practical (88/123, 71.5%) and relevant to dealing with related emotions (93/123, 75.6%). The Desk Pad tool helped focus the SEA on systems issues (85/123, 69.1%), while most found the Report Format clear (94/123, 76.4%) and would recommend it (88/123, 71.5%). Most SEA reports adopted a systems approach to analyses (125/149, 83.9%), care improvement (74/149, 49.7), or planned actions (42/149, 28.2%).Discussion:Applying human factors principles to SEA potentially enables care teams to gain a systems-based understanding of why things go wrong, which may help with related emotional demands and with more effective learning and improvement.

Study of factors related to the reflection abilities of dental trainees.

This study analysed the internal and external factors related to the reflection abilities of dental trainees. We created transcripts from oral presentations by the dental trainees of Hiroshima University Hospital (n=35, 2012-2013) at a significant event analysis conference. The reflection depths were compared between the trainees of the university hospital and external clinical combination groups. We determined and statistically analysed the reflection depths. At the end of training, a Mann-Whitney U-test revealed a significant difference in the median reflection depths of the groups (U=66, W=342 and P=0.007). The results of multiple regression analysis indicated a significant relation between the reflection depth and external training completion (P=0.024). There were no relations with other factors, including gender and academic background. Experiences in external clinics create a close connection between the staff and trainees because communities of practice can cause deeper reflections. We need to create small groups in large-scale organisations such as university hospitals. This construct can be adapted not only for Japanese dental trainees but also for global dental and other medical trainees.

Patient safety in primary care: incident reporting and significant event reviews in British general practice.

Over the past 20years, healthcare has adapted to the 'quality revolution' by moving away from direct provision and hierarchical control mechanisms. In their place, new structures based on contractual relationships are being developed coupled with attempts to create an organisational culture that shares learning and that scrutinises existing practice so that it can be improved. The issue here is that contractual arrangements require surveillance, monitoring, regulation and governance systems that can be perceived as antipathetic to the examination of practice and subsequent learning. Historically, reporting levels from general practice have remained low; little information is shared and consequently lessons are not shared across the general practice community. Given large-scale under-engagement of general practitioners (GPs) in incident reporting systems, significant event analysis is advocated to encourage sharing of information about incidents to inform the patient safety agenda at a local and national level. Previous research has concentrated on the secondary care environment and little is known about the situation in primary care, where the majority of patient contacts with healthcare occur. To explore attitudes to incident reporting, the study adopted a qualitative approach to GPs working in a mixture of urban and rural practices reporting to a Welsh Local Health Board. The study found that GPs used significant event analysis methodology to report incidents within their practice, but acknowledged under-reporting. They were less enthusiastic about reporting externally. A number of barriers exist to reporting, including insufficient time to report, lack of feedback, fear of blame, and damage to reputations and patient confidence in a competitive environment. If incident reporting processes are perceived as supportive and formative, and where protected time is allocated to discuss incidents, then GPs are willing to participate. They also need to know how the information is used, and whether lessons are being learnt from errors.

Assessing the impact of an English national initiative for early cancer diagnosis in primary care.

Background:The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer.Methods:A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not.Results:Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme's effectiveness.Conclusions:Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads.

What can science contribute to quality improvement in general practice?

Over many decades practitioners and academics working in general practice have built a strong reputation for their commitment to developing innovative approaches to improving the quality of patient care. The orientation of these initiatives has evolved over the years. Until the 1980s, providing high quality patient care was primarily reliant on the personal motivation of individual doctors to achieve explicit standards of practice.1 These standards were maintained through a commitment to education and training, and their attainment rewarded by peer recognition, for example by membership or fellowship of professional bodies. From the 1980s until the early part of this century, the emphasis shifted from individuals to teams and the narrative changed from the relatively static orientation of attaining standards to the more dynamic one of continuous improvement.2 Guidelines were developed that had to be delivered by multidisciplinary teams, multiprofessional audit was encouraged, team-based significant event analysis become common, methods of process improvement developed in the manufacturing sector were introduced into practices, and team-based financial incentives were designed and implemented at scale. Over the past decade the focus has shifted again, this time to levers for improvement that operate at a health system level and which place the locus of control more with policymakers and system leaders than with individual professionals or clinical teams. Performance management, competition, transparency, regulation, and legislation have been introduced as ways of potentiating the established professionally-led methods, or replacing them when they are deemed to be failing. In this article we describe what we see as the next phase of the ‘improvement journey’ for general practice, a phase that builds on the strengths of approaches currently being used, and attempts to address their deficiencies. We propose that this will place a stronger emphasis on the role of science — the science of improvement — …

The complex decision making needed in significant event analysis

Bridget Coutts uses the example of a patient presenting with a severe headache to underline the skills needed in differential diagnosis

P81 Significant event analysis in a hospice setting

Monthly significant event analysis (SEA) sessions, which all clinical staff are invited to attend, were introduced at an independent Hospice in 2010. SEA allows opportunity for a team to come...