Knitwear in Southern Russia: Facilitating Learners with Significant Event Analyses - PowerPoint Presentation

Slide1

Knitwear in Southern Russia: Facilitating Learners with Significant Event Analyses

Dr.

Shahid

Dadabhoy

General Practitioner and General Practice Trainer

The

Microfaculty

, 107-109 Chingford Mount Road, Chingford, London E4 8LT

shahid.dadabhoy@nhs.netSlide2

Programme

1300.

Intro

1310

A submission from one of my

appraisees

-small group work (

discussion)

1330

Calibration from the

case

1340

Consensus/discussion on what should be looking for in a log SEA

entry

1400 Knitwear

in Southern Russia (a fictionalised real

case)

1420

Discussion and "

washup

“

1430

EndSlide3

So what is Significant Event Analysis?

“A

process

in which individual episodes (

when there

has been a significant occurrence either

beneficial

or

deleterious

) are analysed in a

systematic

and

detailed

way to ascertain

what

can be learnt

about the overall quality of care, and to indicate any

changes

that might

lead

to future

improvements

.”

NHS National Patient Safety Agency.

Significant Event Audit: guidance for primary care teams

(2008

)Slide4

Case 1

Task

13:10-Have a look at this submission in your groups and discuss.

Record the key points from your discussion.

13:30-Feedback your discussion to the workshop. Slide5

13:40 So what is good SEA evidence anyway?Slide6

The RCGP Line on SEAs?Slide7

The

Seven

S

tages

of Significant Event Audits

Stage

1 – Awareness and prioritisation of a significant event

Stage

2 – Information gathering

Stage

3 – The facilitated team-based meeting

Stage

4 – Analysis of the

SEA

Stage

5 – Agree, implement and monitor change

Stage

6 – Write it up

Stage

7 – Report, share and

reviewSlide8

Stage 1 –

Awareness and prioritisation of a significant event

Staff should be confident in their ability to identify and prioritise a significant event when it happens.

The practice should be fully committed to the routine and regular audit of significant events.Slide9

Stage 2 –

Information gathering

Collect and collate as much factual information on the event as possible from personal testimonies,

written records

and other healthcare documentation.

For

more complex events, an in-depth analysis will be

required to

fully understand causal factors.Slide10

S

tage 3 –

The facilitated team-based meeting

The team should appoint a facilitator who will structure the meeting, maintain basic ground rules and

help with

the analysis of each event. The team should meet regularly to discuss, investigate and analyse events.

These meetings are often the key function in co-ordinating the SEA process and they should be held in a

fair, open

, honest and non-threatening atmosphere.

Agree any ground rules before the meeting starts to reinforce the educational spirit of the SEA and

ensure opinions

are respected and individuals are not ‘blamed’.

Minutes of the meeting should be taken and action points noted. These should be sent to all

staff, including

those unable to attend the meeting.

An effective SEA should involve detailed discussion of each event, demonstration

of i

nsightful

analysis,the

identification of learning needs and agreement on any action to be taken.Slide11

Stage 4 –

Analysis of the significant event

The

analysis of a significant event can be guided by answering four questions:

1. What happened?

2. Why did it happen?

3. What has been learned?

4. What has been changed or actioned

?

The possible outcomes may include:

• no action required;

• a celebration of excellent care;

• identification of a learning need;

• a conventional audit is required;

• immediate action is required;

• a further investigation is needed;

• sharing the learning.Slide12

Stage 5 –

Agree, implement and monitor change

Any agreed action should be implemented by staff designated to co-ordinate and monitor change in the

same way

the practice would act on the results of ‘traditional’ audits.

Progress with the implementation of necessary change should always be monitored by placing it on the

agenda for

future team or significant event meetings.

Where appropriate, the effective implementation and review of change is vital to the SEA process. To test how

well the

SEA process has gone, practices should ask themselves ‘What is the chance of this event happening again?’.Slide13

Stage 6 –

Write it up

It is important to keep a comprehensive, anonymised, written record of every SEA, as external bodies will

require evidence

that the SEA was undertaken to a satisfactory standard. The SEA report is a written record of

how effectively

the significant event was analysed.Slide14

Stage 7 –

Report, share and review

Reporting when things go wrong is essential in general practice. The practice should formally report (either to

the National

Reporting and Learning Service, or via the primary care trust/healthcare organisation) those events

where patient

safety has, or could have been, compromised.Slide15

14:00-Case 2

Maladministration of Vaccines

The task

-Read through the description of the event

-What issues can you identify as a group?

-Record the key points of your discussion

-Feedback to the GroupSlide16

Enhanced Significant Event Analysis – A Human Factors Approach

Paul Bowie, Elaine McNaughton & David Bruce

NHS Education for

Scotland

SEAs

p

erceived as a negative process

“second victim syndrome”

r

eluctance to acknowledge SEAs

s

elective to “safe issues”

p

oor direction to analysesSlide17

“Human Factors Approach”

People factors

(e.g. a newly trained health visitor practising in an immunisation clinic under clinical supervision, while being frequently distracted by parents and colleagues)

Activity factors

(e.g. performing repetitive but different vaccination tasks in a very busy and recently combined immunisation clinic, with similarly labelled vaccinations within immediate reach),

Environment factors

(e.g. a poorly designed workspace layout and immunisation system, and a well-intentioned practice decision to combine clinics to improve efficiency) Slide18

Paul Bowie, Elaine McNaughton & David Bruce

The Human Factors ModelSlide19

The Rashomon EffectSlide20

Knitwear in Southern Russia?What is he on about?Slide21

"

C'est

magnifique

,

mais

ce

n'est

pas la

médecine

.

“

"

C'est

de la

folie

.

"Slide22

Dramatis Personae

FitzRoy

Somerset, 1st Baron Raglan (

CinC

British Army)

Dr R

George Bingham, 3rd Earl of Lucan (

Cmdr

British Cavalry)

Dr L

Brigadier-Gen

Colin Campbell

(

Cmdr

Highland Brigade)

SRN C

James

Brudenell

, 7th Earl of Cardigan (

Cmdr

Light Brigade)

Dr C

General

Sir James

Yorke

Scarlett

(

Cmdr

the Heavy Brigade)

Dr S

Captain Louis Nolan

Dr NSlide23

The Battle of Balaklava 25th

October 1854Slide24

Get it right, nobody remembers…get it wrong nobody forgets

You

live you learn

You love you learn

You cry you learn

You lose you learn

You bleed you learn

You scream you

learn…

From “You Learn” Alanis

Morrisette

1996

Questions ?