At MDS, we’re used to helping GPs to handle complaints and queries when things don’t go to plan. As GPs ourselves, we understand the challenges this job can throw up and we vow to step in with support where and when we can.
Yet, we’re also keen to help GPs by refreshing their knowledge and providing useful tips on what to do if things go wrong.
In this latest post, we’re going to look at significant events and how to react to these. If you’re currently concerned about a significant event and in the midst of dealing with this then don’t hesitate to contact us, otherwise read on for a quick refresher.
The General Medical Council offers a useful definition of a significant event to keep in mind as a GP.
It states: “A significant event (also known as an untoward or critical incident) 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 prevented.”
The following, therefore, are all examples of significant events:
- The unexpected death of a patient
- A diagnosis that was delayed or missed
- A medication error
- A problem arising from a failure of communication
It’s vital to react swiftly and effectively in order to learn the lessons of a significant event.
Why to react to significant events
Significant events call for a significant response. First and foremost, this is because it’s the right thing to do. As a GP, you want to do your level best to look after your patients – and that means learning lessons and adapting your practices whenever required.
On top of this, it’s also important to bear in mind that:
- The General Medical Council requires you to be open and honest if things go wrong and will expect to see evidence of your reaction if a formal inquiry is needed
- The NHS complaints procedure requires you to learn from incidents
- The Care Quality Commission requires you to assess and monitor the quality of your service provision
The requirements of all of these bodies involve reacting appropriately once a significant event occurs.
How to react to a significant event
So, what should you do to ensure you can react properly to significant events? The answer lies in the system, process and people in your practice. Consider the following:
- Staff training is essential. A GP practice is only as strong as its people. Ensure everyone understands your process and that training and retraining forms part of your schedule.
- You need a simple system in place to make it as easy as possible to report and react to significant events. It’s important to revisit this system on a regular basis.
- Communication is a key part of this system. People need to know who to report issues to and work in an environment where they feel they can report these issues without fear.
- When an event occurs, a report should be made and tis must be completely factual.
- There should be someone overseeing the whole process. This could be the practice clinical governance lead.
- A detailed log of any action taken must be kept.
Significant event analysis: The proactive approach
Significant event analysis involves taking a proactive approach. It’s about using the information accrued during and after a significant event and using it to introduce new measures to try to prevent one from occurring in the first place. It should involve the wider team and be an open and honest assessment of the case in question. This isn’t about apportioning blame, rather it’s a case of answering four key questions:
- What happened?
- Why did it happen?
- What has been learned?
- What has been changed or actioned?
Stick closely to these questions – which are those highlighted by the National Reporting and Learning Service (NRLS) – and ensure you’ve answered them fully before the process is complete.
Nigel Sparrow, Senior National GP Advisor and Responsible Officer for the Care Quality Commission, explained: “SEA should act as a learning process for the whole practice. Individual SEAs can be shared between members of staff, including GPs, and should focus on disseminating learning within the practice.”
He notes that SEAs should:
- Identify key events in individual cases (positive or negative) and use them to learn lessons
- Help to embed a culture of openness and reflective learning
- Promote the team ethic needed after a potentially stressful incident
- Reflect on the good elements of practice as well as the things that went well
- Identify training and career development needs
- Share information between teams
He added that when it comes to CQC inspections: “We want to see evidence of learning from incidents and improving quality. On inspection we look for the impact and learning that has resulted from the SEA. We expect ‘good’ practices to ensure that the learning from SEAs involves the whole team and becomes embedded in everyday practice.”
Significant Event Analysis: Resources
The above should hopefully serve as an introduction or refresher into significant events. We appreciate that this is a topic which you might want to read about in greater depth – and you might well want some resources that can help to ensure you are reacting efficiently and effectively when the moment occurs.
Here we’ve picked out some useful resources to assist you with this:
- This PDF is a great example of an SEA form from NHS Scotland that can be used as a template for your own forms.
- NHS Scotland has also produced this guide, which walks you through the decision making process at each stage, broken down into three key phases.
- There are simple and easy to use forms available from the National Association of Sessional GPs, either as a download or as a Google Drive document.
- This is another great toolkit, from Medical Appraisal Scotland, that was designed for sessional GPs.
- The Royal College of GPs has even produced a toolkit that looks specifically at cancer SEAs – with resources and thematic case studies.
If you want to learn more about significant events and how to react appropriately when they occur, get in touch with our team.