Significant Event Audit in Primary Care

In a nutshell: The Improvement Academy has produced a set of resources to enhance the effectiveness of significant event audit in primary care by embedding Human Factors theory into a standardised review process.

The Challenge

Prescribing and drug monitoring errors in general practises in the United Kingdom are estimated to be found in 4.9% of prescriptions with 1 in 550 prescriptions having an error that was considered severe. Significant Event Audit (SEA) is a process that is well established in general practice and community pharmacy. It is recognised that patient safety can be improved by ensuring that SEAs are conducted using a combination of safety science and quality improvement techniques.

What are we doing about it?

As part of our work to improve patient safety, the Yorkshire & Humber Academic Health Science Network’s Improvement Academy has developed entry level ‘train the trainer’ education for members of staff from CCGs across Yorkshire & Humber.  The programme focuses on ‘significant event audits’ in relation to medication errors to illustrate what can be.  It teaches CCG staff how to apply ‘human factors’ thinking to address identified problems.  Human Factors is an approach to enhancing patient safety incident management through an understanding of the common causes of error.

The Slide Set for the train the trainer event can be found here.

The resources that are available for trainers can be found here:

Workshop plan – With objectives and timings  Download
GPs at SEA presentation (Part 1 – Error theory) Download 
GPs at SEA speaker notes (Part 1 – Error theory) Download 
Hand out – Incident decision tree Download 
Hand out – YCFF Download  
Hand out – YCFF checklist Download 
GPs at SEA presentation (Part 2 – SEA Process) Download 
GPs at SEA speaker notes (Part 2 – SEA Process) Download 
Handout Improvement Academy SEA template Download 
Handout NPSA SEA quick reference guide Download 
Handout SEA experience mapping tool Download 
Handout Simply Warfarin worked example Download 
Handout Colecalciferol SEA exemplar Download 
Handout Madopar example with Commentary Download 
GPs at SEA presentation (Part 3 – QI for Safety) Download  
GPs at SEA speaker notes (Part 3 – QI for Safety) Download 
Exercise – Stronger, moderate and weaker barriers.

(for printing and cutting into ‘flash cards’)

Handout – SEA examples for critical appraisal Download 
Medicines Safety Snippets Download

The Improvement Academy would like to thank the CCGs and GP practices that have contributed to the development of these tools.

Our Future Plans

We will be working with CCGs which are early adopters of this approach to embed the tools into routine practice.

To register interest in participating in one of these programmes please contact Tony Jamieson.


Medicines Safety

The Improvement Academy will be working with community pharmacies, hospitals, care homes and CCGs across the region to reduce dispensing errors in pharmacy services, reduce prescribing errors in General Practice and improve medicines safety at transitions of care.