Domain 2:

Safety and Quality: Significant Event Analysis (SEA)

Many Sessional and Out Of Hours doctors are also involved in SEA meetings, either in collaboration with the employer or in a small study group setting.

For appraisal purposes an SEA needs to have involved the doctor personally in some way. There must also be scope for the doctor to reflect on what happened with the appraiser and to consider what changes he/she might make for the future.

The SEA process may also be used to review a very positive event - for example good teamwork in an emergency or a review of a "good death" in a terminal care situation.

Questions that you should address:

What happened?

Describe what actually happened in detail and chronological order. Consider, for instance, how it happened, where it happened, who was involved and what the impact or potential impact was on the patient, the team, organisation and/or others.

Why did it happen?

Describe the main and underlying reasons - both positive and negative - contributing to why the event happened. Consider, for instance, the professionalism of the team, the lack of a system or a failing in a system, lack of knowledge or the complexity and uncertainty associated with the event.

What has been learned?

Demonstrate that reflection and learning have taken place on an individual or team basis and that relevant team members have been involved in the analysis of the event. Consider, for instance: a lack of education & training; the need to follow systems or procedures; the vital importance of team working or effective communication.

What has been changed?

Outline the action(s) agreed and implemented where this is relevant or feasible. Consider, for instance, if a protocol has been amended, updated or introduced; how was this done and who was involved; how will this change or be monitored. It is also good practice to attach any documentary evidence of change (e.g. a letter of apology to a patient, or a new protocol).

Other resources:

Further help is available at NES CPD Connect website.  The direct link is:

http://www.cpdconnect.nhs.scot/peer-review/significant-event-analysis/

Another useful resource is the Enhanced Significant Event Analysis section on the NHSScotland Quality Improvement Hub website:

http://www.qihub.scot.nhs.uk/safe/patient-safety/enhanced-significant-event-analysis.aspx

There are a variety of alternative templates and resources which you may find helpful.  Please see list below.

Related Documents

Seven Practical Steps for SEA | File Size: 146.5 KB | Date Updated: 12/02/2014

This document includes case studies, and dummy sample SEA report.

SEA - Peer Review feedback form (blank) | File Size: 1531 KB | Date Updated: 12/02/2014

This Peer Review feedback tool for SEA reports came from NES, and is used by NHS Greater Glasgow & Clyde's Peer Review Audit and SEA Group. For more information please visit NES website.

Learning from Significant Events | File Size: 185.2 KB | Date Updated: 12/02/2014

Paul Bowie, PhD, associate adviser in postgraduate GP education, NHS Education for Scotland, Glasgow - Bowie P. Learning from significant events. Practice Nurse 2010; 39(12): 11-5

SEA - Report template (blank) | File Size: 1227.16 KB | Date Updated: 11/04/2017

This SEA report template came from NES, and is used by NHS Greater Glasgow & Clyde's Peer Review Audit and SEA Group. For more information please visit NES website. (Please note that the form must be opened via Internet Explorer)

Ideas for Audit: Practical guide for Audit and SEA for General Practice | File Size: 2425.26 KB | Date Updated: 10/02/2015




This page was last updated on: 12/11/2017