Significant Event Analysis

One of the reasons SSGP was set up was to share good practice and learn from significant events. Sessional GPs feel that even if they are able to identify significant events they are not in a position to affect change. Freelance GPs are in an ideal position to identify siginificant events and come up with suggestions for improvement because they work in different Practices and see how they work. The challenge is in overcoming attitudes of learned helplessness, and to receive as well as provide feedback constructively. Provided a good working relationship exists between a sessional GP and a Practice, there is no reason why sessional GPs should not report significant events and be involved in Practice SEA meetings. Therefore, it is always worth addressing a significant event with the Practice concerned before discussion with other sessional GPs who have not been involved with the case. The National Reporting and Learning System (previously the National Patient Safety Agency) has produced a detailed document which is an excellent guide on what SEA involves.

For our meetings we decided to use the Wales SEA template initally but were surprised to find that there was no section for 'why the event happened', therefore we adapted the Deanery template for our own needs. ABMU has its own form to report significant events directly to the Health Board. Resolutions we agreed upon when performing SEA were:

• the person presenting the significant event should provide a print out with a brief description of the event to each member

• Someone should chair and document the meeting

• 30 minutes should be adequate to discuss the event and agree on outcomes

• Small groups of 4 to 10 tend to work well for discussion