Table 1

Summary of standard SEA framework and report format recommended in NHS Scotland

1. What Happened?

• Collate and record as much factual information as possible about the event including, for example, what happened, when and where, what was the outcome and who was involved.

• Record the thoughts and opinions of those involved, including patients and relatives if appropriate, and attempt to form an accurate impression of what happened

2. Why did it happen?

• Ensure the main reasons why the event occurred are fully established and recorded, e.g. was it a failure in a system or a failure to adhere to protocol?

• Establish the underlying or contributory reasons as to why the event occurred, e.g. why was there a failure in a system or adherence to a protocol.

3. What has been learned?

• Agree and record the main learning issues for the health care team or individual team members.

• Ensure that insight into the event has been established by the team or the individuals concerned

4. What has been changed?

• Agree and implement appropriate action in order to minimize the chance of recurrence, where change is considered to be relevant.

• Monitor the implementation of any change introduced

McKay et al. BMC Family Practice 2009 10:61   doi:10.1186/1471-2296-10-61

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