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Introduction
At the beginning of October the NPSA launched new guidance for general practice teams enabling them to learn from both positive and negative significant events. This includes such things as demonstrations of excellent care as well as patient safety incidents and near misses.
The new guidance enables general practice teams to conduct an effective Significant Event Audit (SEA), with the aim of improving care for all patients. The guidance includes an improvement tool to help you develop a structured and effective SEA process by defining the process, outlining effective practices, and demonstrating what can be achieved through real life examples.
There is a quick guide, as well as a full version contained within the guidance. Both take you through the seven stages of a SEA.
What is the background to this?
In the mid 1990s SEA was developed by two GPs and established as an effective quality assurance method in general practice with the aim of improving patients’ experience, care and outcomes, and to identify changes that might improve future care.
In 2004 SEA was incorporated into the Quality and Outcomes Framework as part of the new General Medical Services contract requirements. The NPSA has developed this guidance to raise awareness of how to conduct a SEA and to encourage and inform new and existing users.
So what?
Taking part in SEAs offers general practice teams a chance to reflect and learn from significant events, including those involving prescribing and medicines management such as prescribing errors, communication of medicines information, drug interactions and clinical monitoring. As well as identifying changes that might improve patient care, it also provides an opportunity to enhance team-working, morale, and improve communication between team members and others.
Sharing the learning from SEAs could be a significant step towards improving patient safety in general practice. SEAs can also be developed as a safety tool to be implemented in other healthcare settings.
Action
Everyone involved in prescribing and medicines management in general practice should make themselves aware of this guidance and ensure that they are fully involved in SEAs undertaken by their teams.
Item details
National Patients Safety Agency (2008). Significant Event Audit, Guidance for Primary Care Teams.
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