A retrospective review of significant events reported in one district in 2004–2005

Process analysis

Practice SEA case reports were compared with a standardised SEA format,1 which advocated the identification of learning points; an action plan with implementation dates and shared learning where appropriate; and a resultant review or audit. This process has been a constant feature of the SEA training locally.

Degree of seriousness

Events were also classified according to established National Patient Safety Agency (NPSA) and QOF criteria (Boxes 1 and 2) by type and seriousness. Events that were considered to be ‘patient-safety incidents’ were categorised according to an abbreviated version of the NPSA classification:8 serious or life-threatening (‘red’); potentially serious (‘amber’); or unlikely to be life threatening (‘green’).

The PCT governance team discussed events where the classification was in doubt, or which were considered to be serious or life threatening. Reviewers shared the issues raised with the practices and a consensus on necessary action was reached.

Process analysis

Practices produced learning points from each SEA in 300 cases (89.0%), and action plans in 248 cases (73.6%). At the time of submission for their QOF (31 March 2005), practices reported implemented action plans in 147 SEA's (43.6%). Table 1 summarises the practice processes for SEA and the number of serious or life-threatening events.

Sharing SEA findings internally within teams was recorded in 262/337 events (77.7%). Sixty-three out of 337 events (18.7%) originated outside practices and within partnership organisations, of which 42 (66.7%) were shared by practices with that organisation.

Degree of seriousness

A total of 337 SEAs from 32 practices (mean 10.5 per practice; range 4–17) were analysed. In varying degrees of seriousness, there were 90 events (26.7%) that were patient-safety incidents according to NPSA classification (range 0–9 per practice). Of these, 22 (6.5%) were ‘red’ significant events (serious or life threatening; range 0–3 per practice) and 67 (19.9%) were ‘amber’ significant events (potentially serious; range 2–13 per practice). The one remaining significant event was assessed as ‘green’ (unlikely to be life threatening).

Categories of the significant events reported are shown in Table 2, with serious or life-threatening SEAs in summarised format. Prescribing events and other medicines management events (part of ‘other administrative’) accounted for 96 (28.5%) of the total number of SEAs.

Summary of main findings

Self-analyses of the SEA process by 22 (69%) practices showed that, irrespective of size, practices were performing SEA in a systematic fashion requiring no further support. Four practices appeared to require additional facilitation to implement their identified action plans, but six appeared to have significant difficulties with the whole process of SEA. Table 1 shows that these six practices struggling with the SEA process were small practices (≤2 partners in GP practices).

SEA has been considered an effective educational strategy for general practice.9 Its strength is probably linked to adult learning theory10 and doctors' predilection for tell anecdotes.11 The authors were among many who had facilitated SEA;1^,12^,13 over 10 years finding that most participants could understand and plan the process in facilitated groups. This study also revealed that most practice teams were able to review SEAs and make plans to prevent their recurrence. However, there remains a need to help practices with the implementation of actions identified in SEA, as the action required to improve practice is often more difficult than initially realised.14

SEA is a ‘dynamic technology’, developing rather than being fixed, and inevitably being changed by local practitioners as they adopt it.15 The regulations specify that some events (such as suicide, or death on practice premises) be included, but are otherwise open to broad interpretation. The right set of rewards seems to have been devised for practices to analyse SEAs, but they do not automatically result in effective change.

Strengths and limitations of the study

These routinely reported SEAs are the largest published single series that the authors have discovered from general practice in the UK. Their collection from the routine work of practices across a district should reduce the selection bias inherent in many special projects which commonly involve enthusiasts alone.

The investigation of a large series of SEA reports depends on the understanding of process within practices and their willingness to report appropriate incidents; the format of the reporting scheme; and subsequent analyses. Although practices could have reported incidents in a selective manner, the wide spectrum of events reported here along with the training events observed, suggests this is an appropriate reflection of general practice.

Furthermore, Table 2 shows that 22 serious or life-threatening events were reported, implying local arrangements were trusted to some extent at least. Although it is impossible to know if some events were culled either before or after open discussion in practices, there appears to be openness in the sharing of significant events locally which, it may be assumed, the QOF process has contributed to.

The selection from a single district may limit the application to other settings, perhaps those with a very different history or culture.

Comparison with existing literature

Mechanisms for learning from adverse events in primary care are considered to be less well developed than those in hospitals.16 Little work has been carried out into the analysis of patient safety in primary care.17 Reflection and action from SEAs should be a major part of the drive for quality improvements in the NHS.18 In an analysis of the process of 662 events occurring in Scottish general practices in 2000–2004, most ‘unsatisfactory’ SEAs also showed problems with implementing appropriate action plans.5 Prescribing problems were also a major event category in that series, emphasising the importance of medicines management for patient safety.

An influential Department of Health report, An Organisation with a Memory,16 encouraged the development of an ‘informed organisational culture’ where errors and near-misses could be assessed as the basis for developing safer organisations. The QOF for general practice has now encouraged and rewarded this.

Implications for clinical practice and future research

From public PCT records, 33/35 (94.3%) practices qualified for QOF payments by submitting SEAs, usually by submitting the full quota of 12 SEAs (28/35, 80%). SEAs cost the NHS in England about £4 million in direct payments in 1 year, excluding SEA training and facilitation costs. The events in Table 2 show that a proper system for SEA could deliver savings from greater patient safety and preventable litigation far exceeding this cost.

This review discovered 63/337 (18.7%) SEAs where the major learning points were with another organisation, such as the local hospital. In 42 cases (67%) these learning points were shared appropriately; but in 21 (33%) sharing did not take place (6.2% of all SEAs). This remains a potential weakness of current schemes.

Conclusions and implications for the NHS

In these general-practice SEAs, clear learning points were identified in most (89%) cases. In many cases (74%), action plans had been produced or implemented by the time of submission for the QOF.

SEAs within the QOF reveal many events with important patient safety learning benefits. If SEA is effectively facilitated it is expected to be both cost-effective and increasingly used. The development of local SEA systems, and shared learning with partnership organisations, could do much to support this. Struggling general practice teams are usually ready for help with the SEA process, and this is a critical opportunity to improve patient safety. Primary care organisations and national agencies should build on the momentum of the QOF and nurture the potential of this audit process.