Significant Event Analysis Flashcards
What is SEA?
A way of formally analysing incidents that may have implications for patient care
What is the aim of SEA?
To learn from what went wrong to help improve practice
What are the steps of SEA?
Identify the incident
Report the incident
Act on the incident
Carry out SA audit
What are examples of SEA?
Delayed or missed diagnosis, medication error, communication error
When should an incident be considered for SEA?
Any circumstance where you believe something has gone wrong
How should incidents be reported?
Should be an established method - may be governance/ clinical lead or senior who can advise you
How carry out SEA?
Collect the evidence
Maintain patient confidentiality
Involve the team
Hod a SEA meeting
Decide outcome
Share the learning
What should be discussed in SEA meeting?
What happened
Why did it happen
What has been learned
What has been changed or actioned
What kind of outcomes would expect at SEA?
Identify training
Agreed change management plan w/ timescale
Nominated person to oversee change
Amendments protocol/ policies
