Review of Significant Events

Scottish Medical Appraisal & Revalidation Toolkit Supporting Information Review of Significant Events

Significant Events Analysis (SEA) is a method of reflective learning which can be used to analyse episodes of care which would benefit from further review and reflection and can inform and develop future practice.

SEAs are commonly used to analyse incidents where patients experience unintentional harm - or could have been harmed - as part of the care process. However, the SEA process can also be used to effectively analyse examples of high quality care that can influence service provision.

The numbers of significant events or serious incidents will vary across different specialties. If you have not been involved in any significant events or serious incidents, you must declare this fact - you should either reflect on your local significant event or serious incident process, or what you have been doing well to mitigate the risk of an event or incident occurring.

Where appropriate, you can also complete a reflective template (see bottom of page) relating to specific uploaded documents, groups of documents, or any other additional information or reflections.

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

Questions that you should address:

What happened?

Describe what actually happened in detail and chronological order:

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. You might wish to consider:

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 (individually or collectively as a team) and that relevant team members have been involved in the analysis of the event. Consider:

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:

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).

Remember, 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.

Other resources:

NES has developed an Enhanced SEA e-module which is available on Turas Learn:

https://learn.nes.nhs.scot/903/patient-safety-zone/enhanced-significant-event-analysis-sea (link opens in new window)

For GPs, a further resource is available at the CPD Connect website:

http://www.cpdconnect.nhs.scot/peer-review/significant-event-analysis (link opens in new window)

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

Examples of "SEA" QIA

Questions that you should address:

Other resources:

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