Introduction Significant event analysis (SEA) is proposed as one method to improve the quality and safety of health care. General practitioners (GPs) and their teams are under pressure to provide verifiable evidence of participation in SEA from accreditation bodies and the GP appraisal system in Scotland. A peer review system, based on educational principles, was established in 1998 to provide formative feedback to participating GPs on whether their event analyses were judged to be satisfactory or unsatisfactory.Objectives To identify and classify SEA reports judged to be unsatisfactory, and determine the types of deficiencies and learning issues raised by peer reviewers. Participants and setting GP principals in the west of Scotland region. Design Qualitative content analysis of SEA reports and peer review feedback.Results 662 SEA reports were submitted between 2000 and 2004, of which a potential educational issue was raised in 163 (25%), while a further 75 (11%) were judged to be unsatisfactory. Of the 75 unsatisfactory SEAs, 69 (92%) were classified as having a ‘negative’ impact in terms of patient care or the practice, with only one ‘positive event’ (1%) recorded and three (4%) non-significant events reported. Most events were principally categorised as issues concerned with diagnoses (16%), communication (13%), and prescribing (17%). Learning issues were raised in 67 cases (89%) with regard to the implementation of change; 34 (45%) in understanding why the event happened; 12 (16%) in demonstrating reflective learning; and 11 (15%) in terms of the event description.Conclusions An educational issue is potentially raised for a significant number of GPs in applying the SEA technique. This may impact negatively on the appraisal and revalidation of these doctors as well as on improving patient care and safety. The study has helped to define and share some of the nfactors and inconsistencies that may contribute to an incomplete and therefore an unsatisfactory event analysis. If SEA is to be taken seriously as a risk and safety technique, then it is clear there must be a valid means of verifying and assuring performance in this area.
Paul Bowie , Steven McCoy, John McKay, Murray Lough
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