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Inadequate example: Significant Event Analysis (SEA)

  • Organisations we regulate

Key question: safe?

Population group: All groups

These examples relate to Key Line of Enquiry S2: Are lessons learned and improvements made when things go wrong?

When we inspected

Practice 1

There was no system to record, report and monitor significant incidents while the GP was not at the practice so we do not know how many there were. The locum GP was not sure to whom they would report issues, incidents or concerns; they had not received an induction and had not seen policies regarding incident reporting.

Staff said there was no formal way they were informed and updated about significant events and learning put in place to prevent recurrence.

Practice 2

We saw that the practice had previously had a system in place for reporting, recording and monitoring significant events. Meetings between clinicians in the community and the provider had taken place regularly, and these were used to review and discuss any learning from incidents. However, adherence to those systems had ceased in the autumn of 2013. Since that time, there had been no systems in place to discuss safety incidents and share learning from these.

Why this is inadequate?

By not having a consistent system for recording and learning from significant events, there is potential for repeated patterns of serious incidents.  In addition, without a formal process for raising concerns, stay may not know when to speak up and who to. As a result, risks to safety may not be identified and learning from events or action taken to improve safety is limited.

Information and guidance

Last updated:
10 August 2017