Significant event analysis: a comparative study of knowledge, process and attitudes in primary care

Wet, Carl de; Bradley, Nick; Bowie, Paul

doi:10.1111/j.1365-2753.2010.01509.x

Cited by 9 publications

(15 citation statements)

References 16 publications

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“…Furthermore, we cannot assume that if GPs are prepared to analyse a significant event, they will be able to do so effectively and consistently (NPSA , De Wet et al . ). Although GPs in this study claimed they are competent to carry out incident reporting and analysis, this is not necessarily the case as the degree of analysis varied.…”

Section: Resultsmentioning

confidence: 97%

Patient safety in primary care: incident reporting and significant event reviews in British general practice

Rea

Griffiths

2015

Health Soc Care Community

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Over the past 20 years, healthcare has adapted to the 'quality revolution' by moving away from direct provision and hierarchical control mechanisms. In their place, new structures based on contractual relationships are being developed coupled with attempts to create an organisational culture that shares learning and that scrutinises existing practice so that it can be improved. The issue here is that contractual arrangements require surveillance, monitoring, regulation and governance systems that can be perceived as antipathetic to the examination of practice and subsequent learning. Historically, reporting levels from general practice have remained low; little information is shared and consequently lessons are not shared across the general practice community. Given large-scale under-engagement of general practitioners (GPs) in incident reporting systems, significant event analysis is advocated to encourage sharing of information about incidents to inform the patient safety agenda at a local and national level. Previous research has concentrated on the secondary care environment and little is known about the situation in primary care, where the majority of patient contacts with healthcare occur. To explore attitudes to incident reporting, the study adopted a qualitative approach to GPs working in a mixture of urban and rural practices reporting to a Welsh Local Health Board. The study found that GPs used significant event analysis methodology to report incidents within their practice, but acknowledged under-reporting. They were less enthusiastic about reporting externally. A number of barriers exist to reporting, including insufficient time to report, lack of feedback, fear of blame, and damage to reputations and patient confidence in a competitive environment. If incident reporting processes are perceived as supportive and formative, and where protected time is allocated to discuss incidents, then GPs are willing to participate. They also need to know how the information is used, and whether lessons are being learnt from errors.

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Section: Resultsmentioning

confidence: 97%

Patient safety in primary care: incident reporting and significant event reviews in British general practice

Rea

Griffiths

2015

Health Soc Care Community

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“…Quantitative data consisted of: The practice population at the census date. Number of “significant event analyses” carried out during the 12 month period [ 13 ] Number “who died from cancer” during the 12 month period. ○ Of these, the number who were on the palliative care register when they died and the number who had an electronic palliative care summary when they died.…”

Section: Resultsmentioning

confidence: 99%

Improving primary palliative care in Scotland: lessons from a mixed methods study

Mason¹,

Buckingham²,

Finucane³

et al. 2015

BMC Fam Pract

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BackgroundSince 2012, all GP practices across Scotland have been supported to take a systematic approach to end-of-life care, by helping them to identify more patients for palliative care through a Palliative Care Directed Enhanced Service (DES). We aimed to understand the impact of this initiative.MethodsRoutine quantitative data from the 2012/13, and 2013/14 DES were collected from regional health boards, analysed and discussed. Qualitative data were collected from a sample of 2012/13 DES returns and analysed using Thematic Analysis.ResultsData were received from 512 practices in nine Scottish Health boards for the 2012-13 DES and 638 practices in 11 Health boards for 2013-14. A sample of 90 of the returns for 2012-13 was selected for qualitative analysis.In 2012-13, 72 % of patients who died of cancer were listed on the palliative care register (PCR) before death while 27 % of patients who died as a result of non-malignant conditions were listed on the PCR. In 2013-14, cancer identification remained the same but identification of people dying with other long-term conditions had improved to 32.5 %.We identified several key issues needed to improve palliative care in the community. The need for training to identify patients with palliative care needs (particularly non-cancer); communication skills training; improvements in sharing information across the NHS; under-resource of and lack of coordination with district nurses; improvements in information technology; and tools for working with enlarged palliative care registers.ConclusionsThe DES helped more patients with long-term conditions (LTC) receive generalist palliative care. Approaching generalist palliative care as anticipatory care could facilitate communication between GPs and patients/families and remove some barriers to early identification of palliative care needs. Improvement of information technology and use of identification tools like the SPICT™ may improve professionals’ communication with each other and help may make identification and management of patients easier.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0391-x) contains supplementary material, which is available to authorized users.

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“…Significant event analysis (SEA) is probably the most studied activity in the field of patient safety ( 25 , 26 ). Incident reporting has been promoted as one of the best methods to improve patient safety.…”

Section: Key Research Areasmentioning

confidence: 99%

“…There seems a clear chasm between the high expectations for the event analysis technique and the lack of supporting evidence of its impact on the management of risk and safety in healthcare setting. The evidence for SEA as a team-based educational and problem-solving activity, which may act as a mechanism for change, is at best moderate, but appears to have greater credence where a methodical approach is adopted ( 26 ).…”

Section: Key Research Areasmentioning

confidence: 99%

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

Verstappen

Gaal

Bowie

et al. 2015

European Journal of General Practice

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Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

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Significant event analysis: a comparative study of knowledge, process and attitudes in primary care

Cited by 9 publications

References 16 publications

Patient safety in primary care: incident reporting and significant event reviews in British general practice

Patient safety in primary care: incident reporting and significant event reviews in British general practice

Improving primary palliative care in Scotland: lessons from a mixed methods study

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

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