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Fiona Pollock

Zostera Ltd

Learning Consultant & Coach

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Significant Event Analysis: Not just for Doctors?


I first came across SEA’s (Significant Event Analysis) when I worked in the NHS. It’s  a system which allows practitioners to review and learn from significant healthcare (in the case of the Health Service) events as a way of improving the quality and safety of patient care.

If you aren’t familiar with the process it basically means when something significant happens (i.e. breaches of confidentiality, unexpected death etc) the team involved in the event sit down and systematically review -  in a non-judgemental way – what went wrong, why it went wrong and what can be done to stop it happening again.  The SEA process is intended as learning experience and is not a blame game.

I’ve seen them in action many times and, when well facilitated, they are extremely useful.  Big changes have been made to processes and practices as a result of SEA’s and a discussion with someone a few weeks ago got me wondering about why organisations don’t typically have these in their tool bag as part of their learning portfolio.

Granted, for most organisations a “significant event” won’t be an unexpected death (thankfully), but every business  has their own unexpected events (like a staffing crisis or a serious customer complaint). Wouldn’t it be great if the team involved had an opportunity to sit down, discuss it, understand it and learn from it.  It seems to me an obvious way of getting a positive outcome from an otherwise negative situation.

There are 7 steps to a good SAE process:

1.  Awareness & Prioritisation of the Significant Event – staff have to be confident in identifying when a significant event occurs, and know that they can flag this without fear of being scapegoated or blamed.  (Of course there will be situations where disciplinary action may be required, but this should not form part of the SEA process.)

2.  Gathering information – as much factual information about the event should be gathered as possible.  This might include testimonials, statements, copies of rosters, copies of delivery notes, etc.

3.  A facilitated team-based meeting – a facilitator should be appointed.  This could be someone from the team, or it could be an neutral person who had nothing to do with the event.  A meeting with all individuals who were involved in the event should be arranged.  The facilitators role is to set the ground rules, remind the team of the spirit of an SAE, to structure the meeting and to guide the discussion to ensure a thorough analysis takes place.

4.  Analysis of the significant event – the questions typically asked are:

  • What happened?
  • Why did it happen?
  • What has been learned?
  • What changes have been or need to be made?

There are several outcome options from this discussion, these include:

  • No action required
  • A celebration of excellent service
  • Identification of a learning need
  • Immediate action to be taken
  • Further investigation
  • Sharing the learning

5.  Agree, implement and monitor changes -  An action plan should be developed and agree, with review processes put in place to follow it up.

6.  Write it up – This stage is more critical to the health service and some organisations may feel that they don’t need to document the SAE in as much detail, however, it is always good practice to take minutes of these meetings as they can be referred to further down the line if needs be.

7.  Report, share and review – Knowledge and learning should be shared across the organisation to ensure the same mistakes aren’t made elsewhere unnecessarily.

It is important to note that SEA’s can also be used effectively for situations which went really well – it’s just as important that people understand and learn from these too!

As you can see, the process of conducting an SAE isn’t that complicated.  For it to be truly effective the purpose needs to be genuine:  it needs to be about learning and improving. And it is that is where our challenge lies if we implement this as one of our learning methods.

How do you think SAE’s could be used in your organisation?

Please note: The original SAE guidance was originally developed in partnership between NHS Education for Scotland (NES) and the National Patient Safety Committee.  You can access the SAE quick guide by following this link:

Author Profile Picture
Fiona Pollock

Learning Consultant & Coach

Read more from Fiona Pollock

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