There is no single definition of a significant event.
Practices should record any incident or situation sufficiently out of the ordinary to warrant a permanent record, and perhaps with the potential to prompt action learning or change.
Events may be adverse or may be commendable incidents, and both require a record, a review, and appropriate acknowledgment.
Examples of significant or critical events
Any incident that gives rise to actual or possible physical injury or patient dissatisfaction.
An injury sustained by a member of staff during the course of work
Any near miss i.e. an incident which if it did not cause harm could do so if it happened again.
Post operative infections
Death on the premises
New cancer diagnoses
Mental Health Act admissions
Child protection cases
Inaccurate or incomplete medical records
Delayed or missed diagnosis
Failure in message handling
Events that have resulted in a complaint
Objectives Of Significant Event Reporting
To record incidents that may affect or have affected patients or staff
To record “near misses” so that steps may be taken to prevent a recurrence
To learn from the event as a team, discuss, and put change or procedures in place to improve
To commend and acknowledge good practice
To provide a permanent record of events and evidence of remedial steps taken.
To satisfy the requirements of QOF and nationally required incident reporting standards
To operate and discuss incidents in an open environment and within the safety of a “blame-free culture”
Complete a significant or learning event form that is relevant to your organisation
The completed forms should be reviewed to ensure no ‘immediate action’ needs to be taken
The event should then be discussed in a multidisciplinary team meeting
Actions should be decided by the multidisciplinary team
Minutes should be kept of the meeting
The minutes should be reviewed periodically to ensure the required actions have been completed
If you feel that the event requires learning outside of the practice, complete the official NHS online reporting form