Email updates

Keep up to date with the latest news and content from BMC Family Practice and BioMed Central.

Open Access Highly Accessed Research article

A review of significant events analysed in general practice: implications for the quality and safety of patient care

John McKay1*, Nick Bradley2, Murray Lough2 and Paul Bowie2

Author Affiliations

1 Division of Community Based Sciences, University of Glasgow, Glasgow, UK

2 NHS Education for Scotland, Glasgow, UK

For all author emails, please log on.

BMC Family Practice 2009, 10:61  doi:10.1186/1471-2296-10-61

Published: 1 September 2009

Abstract

Background

Significant event analysis (SEA) is promoted as a team-based approach to enhancing patient safety through reflective learning. Evidence of SEA participation is required for appraisal and contractual purposes in UK general practice. A voluntary educational model in the west of Scotland enables general practitioners (GPs) and doctors-in-training to submit SEA reports for feedback from trained peers. We reviewed reports to identify the range of safety issues analysed, learning needs raised and actions taken by GP teams.

Method

Content analysis of SEA reports submitted in an 18 month period between 2005 and 2007.

Results

191 SEA reports were reviewed. 48 described patient harm (25.1%). A further 109 reports (57.1%) outlined circumstances that had the potential to cause patient harm. Individual 'error' was cited as the most common reason for event occurrence (32.5%). Learning opportunities were identified in 182 reports (95.3%) but were often non-specific professional issues not shared with the wider practice team. 154 SEA reports (80.1%) described actions taken to improve practice systems or professional behaviour. However, non-medical staff were less likely to be involved in the changes resulting from event analyses describing patient harm (p < 0.05)

Conclusion

The study provides some evidence of the potential of SEA to improve healthcare quality and safety. If applied rigorously, GP teams and doctors in training can use the technique to investigate and learn from a wide variety of quality issues including those resulting in patient harm. This leads to reported change but it is unclear if such improvement is sustained.