Enhanced SEA
Chris Williams, Paul Bowie, Elaine McNaughton, Duncan
McNab, John McKay & David Bruce
Quality Education for a Healthier Scotland
Plan
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Analysis of SEA currently
Why enhanced SEA?
Human factors in SEA
Why we blame
Why error occurs
Enhanced SEA process
Results of pilot
Example
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What is a Significant Healthcare Event?
Significant
Event
Patient Safety
Incident
Adverse
Event
(Avoidable
Harm)
Purely
Reflective
Other Quality
of Care Issue
‘Positive’
Event
Near Miss
(Potential
Harm)
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Current expectations of SEA in GPST
• Reflecting and learning from interesting or complex
cases or important safety events
• Identifying individual or practice training needs, and
system weaknesses
• Facilitating the rapid implementation of change
and improvement
• Contributing to the management of risk in the
practice
• Enhancing the safety of patient care and local
safety culture
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Investigations of Significant Events Poorly Conducted:
Problems
• Incidents are highly selective (or non-engagement)
• Lack of a structured analytical framework (long standing issue)
• Many SEAs demonstrate a lack of ‘systems thinking’
• Most clinicians attribute events to their own actions/inactions
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Investigations of Significant Events Poorly Conducted:
Impacts
•
Missed opportunities to learn & improve (personal, team & organisational)
•
SEA becomes a tick-box exercise
•
Perceived blame culture (fear, distrust, punitive action, litigation…)
•
Negative feedback (interferes with ability to assimilate & process
information beyond the ‘self’ level)
•
Second-victim syndrome (impact on health & wellbeing of clinician: guilt,
embarrassment, shame…)
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Why enhanced SEA?
• Overcome SEA deficiencies by introducing human factors
systems principles
• Highlight and differentiate the interactions between the
individual , their workplace and wider organisation.
• Individual Level: guide clinicians to reflect upon and
contextualise their emotional reactions - achieve a state of
psychological readiness to move on.
• may lessen –ve emotional reactions and apportioning of
personal blame
• Team Level: a systems-centred analysis of the significant
event.
• may lead to more meaningful and effective action
plans for improvement.
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Human factors
(Ergonomics)
•
The interaction between humans, systems and the environment
•
What it is NOT!
–
“This mistake was caused by human factors.”
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Human Factors (Ergonomics) in
Healthcare
• In healthcare, it can be used to design all aspects
of a work system to support human performance
and safety, and prevent errors that may harm
patients.
Its goals are twofold:
• To support the cognitive and physical work of
healthcare professionals, and
• To promote high quality, safe care for patients
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Awareness of human factors
principles can help GPSTs to:
• Understand why errors are made and which
‘systems factors’ threaten the safety of patients
• Learn about and help to improve the safety culture
of teams.
• Enhance teamwork and improve communication
between healthcare staff
• Improve the design of “healthcare systems” and
equipment
• Identify ‘what went wrong’ and predict ‘what could
go wrong’
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Why do we blame?
• Convenient
• Prosecute
• Appease patients and public
• Psychological factors
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Blaming ‘Skills’
• Hindsight Bias - this is the ‘I-knew-it-all-along’ effect
• The Illusion of Free Will - Most of us believe that we
determine our own actions (most of the time) In other
words, they ‘choose’ to make mistakes.
• Fundamental Attribution Bias -Our natural tendency is to
attribute someone’s actions (especially undesirable
actions) to their personality traits or characteristics while
(unintentionally) ignoring contextual contributory factors
that may have constrained their actions.
• Just World Hypothesis -We also assume that ‘bad’ things
only happen to ‘bad’ people
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Human Error
“Errors are the inevitable and usually
acceptable price human beings have
to pay for their remarkable ability to
cope with very difficult informational
tasks quickly and, more often than not,
effectively”.
Reason (1990)
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Human error
• Short-term memory capacity
• Gap between the level at which we expect to
perform and reality
• Attention spans
• Our judgment will fail us
• Stress, fatigue and awareness levels can affect
our judgments or perceptions
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Types of Error
Active Errors:
• These are committed by frontline staff and tend to
have direct patient consequences
Latent Errors (or System Errors).
• Latent or system errors create the conditions,
context and potential for Active Errors. They seldom
have immediate consequences, but can
potentially affect many more patients
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Human error – a systems
approach
“Error is not the monopoly of an
unfortunate few” - when placed in
similar circumstances, the majority of
people will make similar mistakes.
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Enhanced SEA
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Enhanced SEA
• Part 1
– Address the personal and wider impact
• Part 2
– Adopt a human factors framework to
analyse why event occurred
• Part 3
– Define the action plan
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Guide Tools
• Small Personal Booklet (with 4 card inserts)
• A3 size Desk Pad
• New written format for enhanced SEA
reports
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1. A small 12-page Personal Booklet (with 4 card
inserts) to help individuals reflect on the potential
emotional impacts of a significant event - and their
own role in the event - by using human factors
principles to gain a clearer understanding of all of
the contributory factors involved.
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2. An A3 size Desk Pad for the care team, the sheets from which can be distributed to all those who attend a
team meeting to analyse significant events. Each sheet contains instructions and prompts to guide the care
team to take a systems-based approach to analysing the event in question and take notes on what was agreed
– a small set of card prompts may also be used in conjunction.
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3. A re-designed
written report
format for
enhancedSEA – to
prompt a systems
based analysis.
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1.About the Significant Event
Please describe what happened
(e.g. outline in sufficient chronological detail including how
it happened, who it happened to and the location of the
event).
What was the impact or potential impact of the event?
(e.g. on the patient/relatives, yourself, colleagues/staff –
think in terms clinical, professional and organisational risks
and implications).
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2.Contributory Human & System Factors
Please outline the different factors that contributed to WHY the event happened.
People Factors (e.g. consider the people (ill patients/clients, staff interactions) who were
directly and indirectly involved in the event and the communications between them and other
factors).
Activity Factors (e.g. complexity of the work task, lack of recognised care guidance or design of
system or process).
Environment Factors (e.g. consider practice culture, time and workload pressures, adequacy of
equipment, available lighting, noise levels, distractions and interruptions.
Please describe how these factors combined to make the event happen.
(Think in-depth about the interactions between people, the activity you were undertaking, the
practice and wider healthcare systems and environment that you work in).
Did you identify these factors on your own or with input from other colleagues?
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Interaction of factors
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3.Lessons Learned
What lessons have been learned from the analysis of this event?
(Think again about the complex interactions between People,
Activity and Environment).
What learning needs have been identified (at the individual, care
team, and organisational levels, where appropriate)?
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4.Action Plan for Improvement
How have you minimised the chances of this event happening again?
(Outline your Action Plan for Improvement and how you have implemented it together with the
role
and contribution of the wider care team, where appropriate. If you have yet to take action or
judge
that no action is necessary, please justify why this is the case).
Who is responsible for ensuring that these actions are implemented and how will these be
monitored and sustained in practice?
(Outline your role and contributions and those of the wider care team, where appropriate).
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Evaluation (n=117)
Statement and levels of agreement (%)
Pre-
Post-
I have a good understanding of what a "significant event" is in the context of my
healthcare role
82
95*
I fully understand how to undertake and lead a significant event analysis
66
95*
When a significant event is analysed, it feels like the person is being written up, not
the problem
19
13
Poor design of systems, rather than the actions of humans, is the biggest factor
contributing to significant events in the workplace
39
50*
I have a good understanding of the discipline of “human factors”
35
77*
Highlighting significant events is a good way of identifying staff who need additional
training
24
34*
48
52
I think undertaking SEA is a demanding and difficult task
*P<0.05
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Early Feedback from SEA Peer
Reviewers
Subjective/Objective Comparisons – ‘Old’ vs ‘New’
• Acts as a ‘forcing function’ – deeper analysis
• More straightforward to actually understand and
peer assess
• Feeling that more challenging events are being
selected
• Overall standard has improved compared with
‘old’ system
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“normal” vs “enhanced”
SEA
120
100
80
60
normal SEA
enhanced SEA
40
20
0
happened
roles
settings
reasons
impact
reflection learning
action
individual
global
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Overall Impact of enhancedSEA
•“I think it was definitely the most thorough SEA that we’ve
done for a while and everybody commented that it went very
well and it had some very good outcomes for us all things that
I really think will have a decent impact”
•“I think it’ll get people to think more into just why significant
event analysis happens and it’s like a big elephant in the room,
of course you’re embarrassed and you will have these
emotions and I think it encourages people to realise that those
emotions are there, we’re not working as robots if you like.
And it gets people to think more about being human”
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Overall Impact of enhanced SEA
• “I found it made the process more laborious
and confusing in some ways. I think the
booklet was helpful but the report format
needs to be simplified. Some of it felt like
writing in order to fill in boxes. I think we
would have come to the same conclusions if I
had used our normal format”.
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SEA unopposed
oestrogen HRT
• 50 year old lady
• No period in 18 months
• Attended ST3 requesting HRT patch
• Prescribed Evorel 25.
• HRT review 1 month later with nurse – inadequate
control symptoms
• PC with ST3– increased to Evorel 50
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Unopposed oestrogen
• Review with nurse 1 month later – HRT
review performed and recorded
• 3 month prescription printed and GP
asked to sign between patients
• Review with nurse 3 months later
• Further 3 month prescription and again
signed by GP between patients.
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Unopposed oestrogen
• Attended GP partner feeling tired
• Reported 3 months of heavy PV
bleeding
• GP double checked HRT
– Apologised
– Gynaecology referral
– USS
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Consider personal impact
on ST3
• “Devastated”
• Loss of confidence
• Was very worried about discussing at
SEA meeting
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What would their first
thoughts be?
• Probably
– Guilt
– Self blame
– Educational need
– “Will try not to do this again.”
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Consider impact
• Patient
• Other patients
• Practice
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Consider people factors
• Patient
• ST3 - Training
• Nurse – training, experience
• GP who signed prescription
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Consider activity
• HRT review
• EMIS prescribing
• EMIS template
• System in place for getting prescription
signed
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Consider environment
• Busy surgery
• 10 minute appointment for HRT review
• GP signing prescription between patients
– Unlikely to check
– Unlikely to question
• Training
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How did this combine?
• Easy mistake to make due to systems
(EMIS)
• Time pressure (ST3, GP, nurse)
• Trying to save patient delay
• Simple mistake not picked up
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Action plan
•
Apology
•
EMIS warning
•
HRT template on EMIS with box to check type of HRT
•
Include HRT in “high risk” medicines tutorial at start of training
•
Have practice “preferred list” of HRT in each room
•
Training of GPs and nursing staff
•
Regular audit - monthly
•
Nominate who is responsible for each action
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Enhanced SEA - Summary
• Enhanced SEA helps
– Discuss “difficult SEAs” which are often PSIs
– Get to the bottom of WHY the event happened
• Exploring people, activity and environment
– Develop and action plan to reduce the risk of
recurrence
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QUESTIONS?
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Enhanced SEA – more
information
• www.nes.scot.nhs.uk/shine/
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