Significant event analysis if carried out correctly can be a powerful learning tool acting as a catalyst for change. A significant event may be defined as “Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice” (Pringle et al 1995).

Significant events can be an event where something has gone wrong, where a less correct course of action has been taken or may be an example of where the system or an individual has worked well and the event is analysed in an attempt to ensure that the system will perform equally well should the same situation arise again. The worked examples include one positive and one negative significant event.

Significant events should not be used to apportion blame, rather, to foster an environment of openness and a willingness to examine practice and systems to improve services and safety.

It is important to have a meeting to discuss the event ideally with people involved in the event or if this is not possible with other clinicians e.g Peer support group.

Significant events are required annually, if you have not been personally involved in a significant event then you should describe the process that occurs in your workplace.

You can record significant events directly into the MARS template or download a template here.

 

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The two examples below demonstrate a positive and adverse significant event:-

Description of event

I was working in the base surgery when a 57 year old man attended, he had a PMH of type 2 DM and had been feeling light headed and sweaty for 4 hours. I had triaged his case myself and arranged an immediate (20 minutes from 1st encounter) base assessment. There was no history of chest pain and the patient had insisted that he felt well in himself otherwise. On arrival it was plain that he was experiencing some sort of cardiac event and I immediately asked the receptionist to call a 999 ambulance and ask the other base doctor to join me. The patient then arrested and the two of us started resuscitation. The resuscitation pack was complete, an appropriate size airway easily found. Both my colleague and myself had attended a resuscitation update organised by the OOH provider (certificate available for inspection) and had been trained in the base defibrillator. We successfully resuscitated this patient and he was conscious when the ambulance arrived. I later discovered he left hospital 10 days later.  

Identify the reasons for the event

I was initially concerned at asking this patient to attend the base; on reflection it was probably the best thing I could have done in the circumstances. I had identified that there was a potential for a serious diagnosis but with a lack of chest pain and other symptoms it could have simply been viral or of non serious aetiology.

What are the learning points?
Everything went well, I acted promptly, used others present at the base to form a team and both doctors were trained in resuscitation and more importantly the use of the defibrillator. I took the patients symptoms seriously and even on reflection appropriately asked him to attend base.
What changes have occurred as a result?
No real changes necessary, this event has been used in a training event specifically for the OOH doctors locally to reinforce the importance of training – the OOH provider now has trained 100% of their doctors and nurses in resuscitation and use of the defibrillator.

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Description of event
I was performing a session of telephone triage combined with a base surgery later – all the patients I asked to attend the centre would need to be seen by me. At the end of my triage shift a call came in for a 57 year old man with back pain that had only been present for 2 hours requesting a visit. I advised analgesia as the patient had not even taken a paracetamol. Three hours later a further request for an urgent visit was made and it transpired that the visiting doctor made a diagnosis of renal colic and had to admit the patient who was in extreme pain.
Identify the reasons for the event
I dealt with this call at the end of a telephone shift after which I was performing a base face-to-face session. I recall being a little jaded with giving telephone advice and when I looked at my clinical records I had not taken a full history. I had assumed short-lived back pain as being musculo-skeletal in origin and had probably been quite short in my advice. Fortunately (although painful) the back pain was not due to a life threatening cause (such as aortic aneurysm) and the patient had the sense to ring back.
What are the learning points?
Take a full history no matter how trivial – telephone encounters remove the ability to eyeball the patient and make a visual assessment. My clinical records of the encounter were inadequate and I had not used the safety net of advising recall as required.
What changes have occurred as a result?
I now make every effort to treat my last telephone triage with equal importance to the first. I will also examine my record keeping in particular with respect to telephone triage. This is a potential “near miss” and I will use this as a learning point and change my practice and try not to be short with patients that call with seemingly trivial or short-lived symptoms.