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No matter how busy, tackle significant event analyses

Significant event monitoring in practices is worth it even if time is short

and the practice busy, says Dr Andrew Carson, who writes from experience

A Government-funded study has shown pressure of work is preventing a worrying number of GPs learning from practice errors. Recently published research on 466 principals in Glasgow revealed 86 per cent reported being aware of a recent significant event associated with their practice but a significant number failed to investigate the episode fully.

I know the life of the GP and the rest of the primary care team has never been busier, and for most of us the pressures of the new contract have had to be fitted in alongside an already packed timetable, but I believe everything possible should be done to analyse a significant event and implement a policy to stop something similar happening again.

Wrong vaccine given

In my inner-city practice we had an untoward incident some 16 months ago in which an infant was given the MMR vaccine instead of DTP. The incident received adverse publicity because of the topical nature of the MMR vaccine and this necessitated a rapid onset of information gathering, analysis and reflection within the team.

The event was a complicated one that turned out to have a number of contributory factors. The size of our practice team enabled us to deal rapidly and effectively with the media attention through cover from colleagues.

Smaller teams may have more of a struggle, but they would certainly be wise to take the time to undertake a broad significant event analysis soon after the event and learn about dealing with the press, as it can be extremely stressful.

They should also find out about what went wrong in the first place. Failure to so means the significant event could occur again, particularly if the problem lies with the practice policies and procedures rather than straightforward human error. Following our experience I would say a practice team must at all costs prioritise significant event analysis. It has been said that, given the current pace of change in today's world, the old adage of 'if it ain't broke, don't fix it' should be changed to 'if it ain't being constantly fixed it is probably broken'. I agree.

In our specific case, the initial period of information gathering revealed a number of potential contributory factors to the incident. They were as follows:

lA new member of staff undertaking a clinic on their own for the first time following a period of in-house training

lInterruptions to the vaccination appointment

lPotential problems with vaccine identification during maintenance of the cold chain

During our investigation several staff involved in the incident, as well as parents of children with our practice, made suggestions as to how our systems could be improved so as to avoid the risk of such an incident recurring. Suggestions for improvement included those listed in the box on the opposite page.

Some of these ideas were fairly simple and were trialled before the time of the team-wide significant event analysis. This allowed for an even more informed discussion of relevant issues at the time of the meeting.

Furthermore, although the parents did not attend the significant event analysis meeting itself, they were intimately

involved in discussions throughout the entire process.

While this felt quite threatening at the time, it proved to be a highly effective strategy, with the parents feeling they had made a positive contribution to the future safety of immunisations both at our practice and beyond.

This approach also demonstrated to the parents how seriously we viewed the incident and we managed to maintain an excellent relationship with them throughout this difficult time.

In terms of the learning that came out of the process for us,

we were able to develop a number of skills relating to handling a serious untoward incident with involvement of the press.

In addition, we took the opportunity to reflect on our training and assessment of new staff to ensure greater patient safety.

We also came to understand the

positive benefit of involving patients in this process.

To conclude, failure to learn from errors or near-misses in practice could lead to considerable time wasting or worse later on. However busy and stressed you are, it is always worth it.

Andrew Carson is a GP in Birmingham

Procedures we looked at

lHow did we assess the effectiveness of staff induction and training?

lShould there be a more formal assessment of training to ensure its effectiveness?

lHow frequently should staff undergo assessment?

lCould we improve the checking

of immunisations prior to administration?

lShould we show parents vaccines before administering them?

lHow could we improve our handling of the press?

lDid we need specific training in handling the press?

lWould it be helpful to have a script for a 'dry run' Serious Untoward Incident so that everyone became familiar with it?

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