Summary
Significant event analysis can help general practices understand why something went wrong, identify risks and improve patient safety. However, recording an event or discussing it at a meeting does not automatically produce meaningful learning. Practices need an open reporting culture, a proportionate method of review, and a reliable process for implementing and monitoring improvements.
In this blog, Liam Stratton, a former Care Quality Commission (CQC) inspector, outlines six ways practices can improve their approach. These include making reporting accessible to every member of staff, examining reporting systems, involving patients where appropriate, turning findings into measurable actions and sharing learning across the organisation.
Content
1. Significant events should support improvement
Significant events are often completed as part of revalidation or a box ticking exercise. The real purpose of significant event reporting is to reduce the risk of patients being harmed and facilitate learning.
The General Medical Council (GMC) guidance on significant events defines it as an unintended or unexpected event that could or did result in patient harm. The guidance requires doctors to report and reflect on events that they were involved in, as well as events involving other team members within the service.
Importantly, the GMC states that reflection should concentrate on insight, learning and improvements to practice rather than simply describing what happened within the incident report.
In my experience of reviewing governance systems in primary care, practices that excel are the ones that treat significant events as an opportunity to reflect, improve and share learning.
Practices will often only report incidents that they consider to be more serious or where harm occurred. A reportable incident should be anything that deviates from the mean. This could include less serious events, such as a vaccine fridge temperature temporarily being outside of the recommended range or a referral was sent to the wrong department but identified and redirected without delaying care. Actual significant harm does not need to occur in order for the incident to be a useful learning event.
2. Make reporting accessible to everyone
Every member of the practice team should know what to report, how to report it and who to report it to. This includes locums, trainees, receptionists and temporary staff. A clear incident reporting policy should be in place and accessible to all team members. Staff should be trained on the reporting system and be given the autonomy to raise significant events themselves.
As previously mentioned, reports should not be restricted to incidents that caused serious harm. Near misses, communication failures, delayed referrals, prescribing errors and problems with test-result handling should be logged and fully investigated.
The CQC has published reports containing inadequate practice where there was no reliable system for recording and monitoring significant events, where locum staff did not understand the reporting process and where learning was not communicated to the wider team.
A straightforward reporting form, supported by training and regular discussion, is often more effective than an elaborate process that staff find difficult to use.
3. Create a culture that supports speaking up
Staff are less likely to report incidents if they expect blame, criticism or disciplinary action. Leaders should respond with fairness and an open mind while recognising that it is only human to make mistakes. During a CQC inspection, inspectors may review the circumstances and causes of an incident, but their main focus will usually be how the provider responded and what was learned. For example, if a member of staff made an error, the provider should consider whether they had received appropriate training and supervision, whether procedures were clear and whether wider system factors contributed. Inspectors may then look for evidence that appropriate action was taken and that any improvements were implemented and monitored.
Your investigation could ask the following questions:
What conditions led to the event?
Were the procedures easy to follow and understood?
Did workload, staffing, equipment or technology contribute?
Were there communication problems between people or organisations?
What controls were absent or ineffective?
Were staff provided with appropriate training?
This approach does not remove accountability. It helps the practice distinguish individual accountability from problems created or exacerbated by the processes in place.
4. Use a proportionate review
Not every incident requires an extensive investigation. The response should reflect the level of harm, potential for harm, complexity and likelihood of recurrence. Incidents should be given a risk score, i.e likelihood x impact. The score should help determine the urgency and depth of the review, the level of oversight required and whether the incident needs to be escalated or reported externally.
A short team discussion may be sufficient for a low risk near misses. A more complicated incident, such as a prescribing error, may require a structured investigation, information from several staff members and involvement from external organisations.
The NHS Patient Safety Incident Response Framework (PSIRF) supports organisations to develop and maintain effective systems for responding to patient safety incidents. It is built around four key aims:
1. To engage with those affected by patient safety incidents.
2. To use system-based approaches to learn from incidents.
3. To ensure responses to incidents are considered and proportionate.
4. To provide oversight that strengthens incident response systems and drives improvement.
Whatever approach is taken, the purpose should be to understand what happened, support those affected and reduce the risk of the incident happening again.
5. Duty of Candour
Where a patient has been affected by an incident, practices should communicate openly, compassionately and in accordance with CQC regulation 20: Duty of Candour.
CQC expects providers to act promptly as soon as a safety incident has been discovered. Involvement with the patient affected should be meaningful and candid. Patients should be told what will happen next and how the practice will communicate the outcome. Apologies should always be given, as well as a written explanation about the incident.
The practice also needs to identify if the incident needs to be reported externally. For example, data breaches may need a notification sent to the Information Commissioners Office (ICO) and anything that falls under statutory notifications need to be reported to the CQC.
6. Track whether improvements make care safer
An incident is not resolved just because it’s been discussed in a meeting. Each agreed action should have an owner, deadline and method for checking completion. Having a physical tracker in place is beneficial to closely monitor where actions are up to. Progress should be discussed in team meetings to keep all staff up to date of any changes being made.
Practices also needs to consider if learning actions have been successful in preventing the incident from recurring. Any improvements must be communicated to staff members, and the best way is to candidly discuss them in a team meeting—and always minute the meeting, as this evidence may be requested during a CQC inspection.
Practices should also consider sharing information within their local network. This could be within your Integrated Care Board (ICB) or within wider networks. NHS England’s Learn from Patient Safety Events service also allows safety events to contribute to national learning by reporting through a centralised system so that safety issues can be quickly identified and acted upon.
An annual review of incidents can help the practice identify recurring issues, emerging trends and areas requiring further improvement. It can also show whether previous actions have reduced the likelihood of similar incidents happening again.
Conclusion
Significant event analysis should lead to action, rather than simply producing a completed form. Any learning should be shared, agreed improvements implemented and their effectiveness reviewed.
The real measure of the process is what happens afterwards. When practices identify contributing factors, involve those affected, complete agreed actions and check whether those actions have worked, reflection becomes a practical way to reduce risk, strengthen systems and make care safer for patients.
About the author
Liam is a former Care Quality Commission inspector with experience across primary care and oral health. He now supports healthcare providers with governance, regulatory compliance and continuous improvement through CQC Consultancy.
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