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Your first... critical incident analysis

Dr Stefan Cembrowicz advises on the process of learning lessons and making changes when something has gone wrong

Dr Stefan Cembrowicz advises on the process of learning lessons and making changes when something has gone wrong

Critical incident analysis was defined by Professor Mike Pringle, then RCGP president, in 1995 as 'individual episodes in which there has been a significant occurrence (either beneficial or deleterious) which are analysed in a systematic and detailed way to ascertain what can be learned about the overall quality of care and to indicate changes that might lead to future improvements'.

In today's climate of reflective practice committed to quality improvement, it is important to review situations where clinical events have not gone as well as they could have. This could be a minor problem – such as Professor Pringle's original example of out-of-date aspirin in his doctor's bag – or serious circumstances surrounding a patient's death. Your write-up may be brief or lengthy but the process is the same. Significant event audits (SEAs) use a similar approach but can be used after successful incidents. (The NHS is weak at celebrating its successes.)Critical incident analysis values people, and to be effective comes from a team. When done well it encourages openness, aims to improve systems rather than blame individuals. And it is a way in which doctors can demonstrate team leadership.

How to start

• Make notes of observations and facts at the time of the incident, and develop them later as events crystallise.

• Comment on your own feelings and responses at the time and just after the incident.

• Consider if another person's point of view might interpret this event differently.

• Talk it through with colleagues. Focus on system improvement, not individuals.

• Concentrate on the 'no blame' approach.


• What significant factors were involved (systematic or individual)?

• What have you learned from this – about colleagues and about yourself?

• What changes can be made?

• How would you do this better next time?

Writing up outcome

The write-up does not have to be lengthy – one page will suffice. It is likely to include:

• any immediate actions needed

• unresolved issues – an opportunity for further quality improvement

• plaudits – compliment those who did well during the event

Maybe no action will have been taken – though colleagues will have benefited from airing their views.

What to do with your findings

Network with a colleague and present your review to your primary care team – having agreed beforehand on confidentiality and anonymity. This approach should be implicit in the culture of your team, as a method of continuous quality improvement and as part of regular team meetings.

Critical incident analysis helps you not only reflect on how you work but also demonstrate reflective practice as part of your own lifetime learning. Record it in your learning portfolio and plan to repeat the exercise in the future.

Analyses are more thought-provoking and more likely to induce change than most audits, as they are based on real events where something has not gone well. When something goes wrong in healthcare it can be quite shocking. Using the model of routine systematic incident analysis will help improve the quality of the system quickly, to prevent similar events next time around.

Dr Stefan Cembrowicz is a GP trainer in Bristol

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