662:
In the meeting, those involved in the event present what happened in the case, followed by questioning and a group discussion about how the situation was dealt with. Actions and a follow-up meeting may be necessary with agreement and the process is recorded as a summary. The SEA is then documented on
468:
Events triggering a SEA can be diverse, include both adverse and critical events, as well as good practice, and are a structured way of reviewing an occurrence that caused harm, a near miss or an identified risk, or a reason for celebration. With the aim of being a positive development, it can cover
343:
in the UK, with a view to improving patient care and services. To be effective, the SEA frequently seeks contributions from all members of the healthcare team and involves a subsequent discussion to answer why the occurrence happened and what lessons can be learned. Events triggering a SEA can be
836:
Restrictions due to the time needed to perform SEA may cause difficulty in going through the process. Other restrictions may include resistance to honesty, the process being emotionally demanding and uncomfortable, and lack of motivation. Leadership and group dynamics may vary and there may be
380:(MDU) defines SEA as "a way of formally analysing incidents with implications for patient care in order to improve services". For the purposes of appraisal and revalidation a SEA is "any unintended or unexpected event, which could or did lead to harm". This is reflected in the
388:
an untoward or critical incident...which...is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been
1286:
372:
a process in which individual episodes are analysed, in a systematic and detailed way to ascertain what can be learnt about the overall quality of care, and to indicate changes that might lead to improvements.
449:. The value of using SEA was highlighted in the publication of the GP contract of 2004, and became part of the GP contract in the UK, with practices requiring to have completed 12 SEAs every three years.
398:
SEA may also be referred to as a serious untoward incident, patient safety incident, critical event audit, critical incident analysis, structured case analysis or facilitated case discussion.
1084:
1716:
857:, to identify successful and adverse aspects of "combat leadership". Its application now extends to business, organisational psychology, education and healthcare.
885:
1137:
821:
620:
A timeline of the SEA is assembled with the facts gathered via medical records and personal accounts and interviews. This can then be further analysed.
406:
SEA is mainly a concept from the UK, where team members come together to constructively review an event that has occurred, broadly equating to doing a
282:
1611:
883:, published a "groundbreaking" paper on SEA. They helped instigate and develop SEA into primary care in the UK. Following the publication of
1260:
1465:
273:
1519:
1168:
893:
was established in April 1999, and subsequently two more documents further promoted SEA as a way of delivering clinical governance.
1375:
601:
To identify individual events whether beneficial or detrimental and to improve the quality of patient care from the lessons learnt.
1233:
1349:
1711:
1180:
191:
1317:
1773:
1732:
1044:
318:
1690:
1763:
1578:
628:
The SEA is frequently set as an agenda item within a wider group meeting, but a separate meeting may also be arranged
1604:
1414:
1270:
1243:
1056:
242:
72:
915:
1809:
247:
1814:
1458:
344:
diverse, include both adverse and critical events, as well as good practice. It is most frequently required for
1437:
1387:
457:
166:
1768:
384:'s (GMC) definition which is not the same as that frequently used in primary care. The GMC describe a SEA as;
1804:
1597:
1404:
814:
807:
1737:
846:
290:
1799:
1778:
1742:
1670:
1451:
802:
External agencies that may require access to SEA documents include patients and carers, GP appraisers,
186:
880:
652:
1685:
1680:
876:
427:
353:
311:
267:
216:
161:
57:
1634:
381:
376:
It does not necessarily involve an undesirable outcome and can reflect good or bad practice. The
47:
1706:
237:
171:
77:
1552:
1493:
1433:
419:
377:
365:
345:
211:
201:
156:
794:
There is no fixed end point, hence outcomes can be re-evaluated at predetermined intervals.
1665:
872:
435:
141:
8:
1675:
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1488:
1474:
890:
817:
803:
787:
415:
304:
146:
136:
22:
1747:
1547:
1138:"Significant events;Myth: GMC significant events are the same as GP significant events"
825:
176:
131:
82:
1262:
Key Tools and
Techniques in Management and Leadership of the Allied Health Professions
969:
845:
The method of SEA, focusing on the team rather than the individual, is founded on the
1644:
1639:
1573:
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1410:
1383:
1266:
1239:
1176:
1112:
1052:
109:
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850:
181:
104:
1406:
The
General Practice Journey: The Future of Educational Management in Primary Care
1509:
453:
206:
196:
151:
67:
1660:
1568:
1542:
1350:"Nigel's surgery 3: Significant event analysis (SEA) | Care Quality Commission"
632:
if necessary. Attendees usually comprise a few or a number from the following;
431:
52:
438:
and considered as a form of quality improvement activity, as events of SEA in
1793:
864:, seriously untoward events were analysed via a number of methods including
1537:
865:
495:
446:
439:
423:
411:
349:
340:
62:
1196:
339:, is a method of formally assessing significant events, particularly in
407:
30:
1589:
1443:
368:'s occasional paper on the topic in 1995, where, he defined SEA as;
582:
1049:
Clinical Audit in
Primary Care: Demonstrating Quality and Outcomes
1318:"Reflecting on significant events during GP training | GPonline"
1169:"Chapter 14. Significant event auditing and root cause analysis"
813:
GPs are now encouraged to report and share SEAs via their local
629:
501:
1717:
List of international healthcare accreditation organizations
1434:“Significant Event Audit; A Guidance for Primary Care Teams”
767:
The discussion may lead to a number of outcomes including;
604:
To encourage openness, rather than blame or self-criticism.
868:, clinico-pathology meetings and confidential enquiries.
861:
1051:. Seattle: Radcliffe Publishing Oxford. pp. 28–35.
783:
A review of the literature or guidelines and report back
610:
To identify good practice, in addition to poor practice.
613:
To be useful for continuing professional development.
663:
a form which is frequently bespoke to the practice.
518:
registering a diabetic person with sight impairment.
822:
Medicines and
Healthcare products Regulatory Agency
736:Contributing factors as to why the event happened.
364:The concept of SEA was established with the aid of
1378:. In Harrison, Jamie; van Zwanenberg, Tim (eds.).
1287:"Your supporting information – significant events"
1083:Ashmore, Stephen; Johnson, Tracy (1 August 2006).
1791:
970:"Significant Event Audit. Information about SEA"
963:
961:
959:
957:
726:Detailed description of what actually happened.
1038:
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1016:
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1000:
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990:
916:"What is a significant event audit? - The MDU"
756:Agreed action and show how it is implemented.
445:It can also be used as part of a GP trainee's
1605:
1459:
1311:
1309:
1307:
1078:
1076:
1074:
1072:
1070:
1068:
515:sudden unexpected death or hospital admission
312:
1258:
1227:
1225:
1223:
1221:
1219:
1217:
934:
1396:
1367:
1235:Patient Safety and Managing Risk in Nursing
1231:
1107:
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987:
442:frequently do not meet the harm threshold.
1612:
1598:
1466:
1452:
1382:. Radcliffe Publishing. pp. 151–158.
1304:
1279:
1171:. In Hurwitz, Brian; Sheikh, Aziz (eds.).
1065:
910:
908:
906:
616:To share SEA between teams within the NHS.
469:clinical as well as administrative areas.
319:
305:
1520:List of health departments and ministries
1252:
1232:Fisher, Melanie; Scott, Margaret (2013).
1214:
1162:
1160:
1158:
967:
414:situations and has some comparisons with
1102:
1619:
1473:
1373:
1166:
903:
1792:
1712:International healthcare accreditation
1344:
1342:
1340:
1338:
1315:
1259:Jones, Robert; Jenkins, Fiona (2011).
1155:
1130:
820:. Other reporting systems include the
1593:
1447:
1265:. Radcliffe Publishing. p. 116.
1189:
1173:Health Care Errors and Patient Safety
1043:Chambers, Ruth; Wakley, Gill (2016).
837:conflicts of interest between staff.
746:Demonstrate reflection and learning.
418:. It is most frequently required for
1774:Incremental cost-effectiveness ratio
1733:Incremental cost-effectiveness ratio
1403:Swanick, Tim; Jackson, Neil (2018).
1691:Routine health outcomes measurement
1380:Clinical Governance in Primary Care
1335:
1316:Naidoo, Prashini (4 January 2017).
968:Henderson, Roger (29 August 2014).
428:continuing professional development
354:continuing professional development
13:
1764:Clinical Quality Management System
1427:
1197:"Significant Event Audit Web Site"
1085:"Guide to significant event audit"
643:nurses – practice and/or community
571:
14:
1826:
671:Significant Event Audit Template
547:
243:Sustainable Governance Indicators
1376:"12. Significant Event Auditing"
1238:. Learning Matters. p. 45.
248:Bertelsmann Transformation Index
1436:, Paul Bowie and Mike Pringle,
831:
539:confusion between patient names
509:avoidable admission to hospital
410:. It is preferentially used in
1438:National Patient Safety Agency
1117:GP Appraisals and Revalidation
623:
458:National Patient Safety Agency
1:
1769:Disability-adjusted life year
896:
808:clinical commissioning groups
475:
456:technique is endorsed by the
359:
828:for adverse medical events.
797:
581:monitoring medications e.g.
7:
1738:Cost-effectiveness analysis
847:critical incident technique
762:
607:To encourage team-building.
554:missing medical information
393:
291:Market governance mechanism
274:Governance, risk management
10:
1831:
1779:Quality-adjusted life year
1743:Cost-minimization analysis
1671:Independent medical review
840:
523:
337:significant event analysis
283:Environmental, social, and
1756:
1725:
1699:
1653:
1627:
1561:
1530:
1502:
1481:
1175:. John Wiley & Sons.
853:by aviation psychologist
653:allied health professions
485:diagnosis of a new cancer
482:childhood infection cases
463:
1686:Health services research
1681:Health impact assessment
472:Examples could include:
268:Chief governance officer
1810:National Health Service
1654:Health care evaluations
1635:Evidence-based medicine
849:, developed during the
595:
587:violent attack on staff
382:General Medical Council
333:significant event audit
1815:Health care management
1707:Hospital accreditation
1374:Pringle, Mike (2000).
1167:Pringle, Mike (2009).
1089:Pharmaceutical Journal
752:What has been changed?
742:What has been learned?
578:adverse drug reactions
401:
391:
374:
238:World Governance Index
1553:Waiting in healthcare
1494:Health administration
1201:projects.exeter.ac.uk
886:A First Class Service
873:general practitioners
810:(CCGs) and the (GMC.
536:confidentiality issue
506:osteoporotic fracture
386:
378:Medical Defence Union
370:
335:(SEA), also known as
1666:Clinical peer review
1113:"Significant events"
713:Team members present
285:corporate governance
1805:Health care quality
1676:Health care ratings
1628:Concepts of quality
1621:Health care quality
1489:Clinical governance
1475:Clinical governance
891:clinical governance
818:clinical governance
804:clinical governance
788:root cause analysis
695:Date of SEA meeting
488:unplanned pregnancy
416:root cause analysis
1748:Cost per procedure
1726:Costs and benefits
1548:Cost per procedure
1045:"2. Audit Methods"
826:Yellow Card Scheme
732:Why did it happen?
566:unactioned request
542:a staffing problem
491:underage pregnancy
1800:Types of auditing
1787:
1786:
1645:Medical guideline
1640:Medical consensus
1587:
1586:
1574:Medical guideline
1515:Health department
1182:978-1-4051-4643-2
760:
759:
563:missed home visit
560:referral not sent
329:
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1322:www.gponline.com
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855:John C. Flanagan
851:Second World War
774:Immediate change
666:
665:
657:patients, carers
640:practice manager
321:
314:
307:
167:Higher education
73:Multistakeholder
18:
17:
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1579:Medical strikes
1557:
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1510:Health minister
1498:
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1428:Further reading
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1142:www.rcgp.org.uk
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1119:
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790:and report back
765:
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572:Risk Management
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187:Political party
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1569:Clinical audit
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1543:Length of stay
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1354:www.cqc.org.uk
1334:
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1291:www.gmc-uk.org
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722:What happened?
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1409:. CRC Press.
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922:. 25 May 2018
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860:Within the
771:Celebration
704:SEA lead(s)
649:secretaries
624:The meeting
533:compliments
436:qualitative
172:Information
78:Open-source
48:Algorithmic
1794:Categories
1389:1857758617
897:References
824:'s (MHRA)
530:complaints
476:Prevention
408:case study
389:prevented.
360:Definition
212:Technology
202:Simulation
63:Electronic
31:Governance
798:Reporting
780:No action
452:SEA as a
434:, SEA is
420:appraisal
346:appraisal
142:Corporate
1562:Practice
763:Outcomes
583:warfarin
394:Synonyms
231:Measures
147:Cultural
137:Clinical
124:By field
97:By level
23:a series
21:Part of
1531:Metrics
1359:30 June
1147:30 June
1094:29 June
926:26 June
841:History
524:Service
512:seizure
177:Network
132:Climate
83:Private
1482:Theory
1440:(2008)
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630:ad hoc
502:stroke
464:Events
110:Global
40:Models
1757:Tools
777:Audit
677:Title
182:Ocean
105:Local
1411:ISBN
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1361:2019
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1177:ISBN
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981:2019
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879:and
596:Aims
500:new
494:new
426:and
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207:Soil
197:Self
152:Data
68:Good
862:NHS
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402:Use
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