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Evaluation of a Primary Care Safety Improvement Intervention using Enhanced Significant Event Analysis in a Regional Scottish Health Board

Duncan McNab,John Freestone, John McKay, Paul Bowie

Background: In primary care, Significant Event Analysis (SEA) is an established method for learning and improving from patient safety incidents. The enhanced SEA method was developed to facilitate a deeper, systems approach to improve the effectiveness of analyses. Completion and submission of enhanced SEA reports to the national education and training authority for peer review was a component of an optional enhanced service for general practices in Ayrshire and Arran health board. The aim of this study was to theme incident types, improvement actions described and conducts inter-group comparisons of the quality of event analyses.

Methods: Two team members from participating general practices attended two half-day training sessions and completed and submitted an enhanced SEA report for peer review using a validated tool. Content of submitted reports was thematically analysed independently by two researchers. Peer review rating scores were used as a proxy indicator of quality and were compared with similar data from other GP groups. Quantitative data were analysed using descriptive and inferential statistics.

Results: Fifty-one of 55 practices participated (93%), submitting 52 SEA reports. 113 improvement actions across five different care systems were described (mean 2.2). Protocol creation or alteration was described most frequently (35%) whereas individual action was described in 5%. Of the 12 SEAs describing communication problems with other healthcare sectors, seven were discussed with professionals outside the practice (58%). Two SEAs described direct involvement of the patient (3.8%). The majority of the enhanced SEA reports described events whose consequences were negligible or minor (86.6%). Grading of reports were similar to prospective trainers and specialty trainees.

Conclusion: After training, GP teams were largely able to use the enhanced SEA method to analyse events and implement system-level actions. Consideration of how to improve the analysis of events across healthcare interfaces, involve patients to maximise learning and increase incident reporting is needed.