A retrospective review of significant events reported in one district in 2004-2005

Patient safety is a key issue in primary care. Significant event analysis (SEA) is a long established method of improving safety. In 2004, SEA was introduced as part of the Quality and Outcomes Framework (QOF) of the new general medical services (GMS) contract.

To review SEAs submitted for the QOF by general practices for a primary care trust (PCT) in 2004-2005.

A retrospective review of SEAs.

St Helens PCT, Merseyside, North West England, UK (185 000 patients), now part of Halton and St Helens PCT.

Three hundred and thirty-seven QOF-reported SEAs were reviewed from 32 (91%) of a total of 35 St Helens PCT practices (mean 10.5, range 4-17).

Practices identified learning points in 89% of SEAs. Twenty-two of 32 (69%) practices successfully performed SEA and required no further support. Four practices identified learning points but needed further facilitation in implementing change or actions arising from SEA. Six practices had significant difficulties with SEA processes and were referred for extra SEA training locally. Ninety (26.7%) of all significant events were classified as patient-safety incidents. Of these, 22 (6.5%) were 'serious or life threatening' and 67 (19.9%) were 'potentially serious'. Ninety-six (28.5%) of the significant events related to medicines management issues; and 63 (18.7%) had key learning points for partnership organisations. Main outcome measures were review of SEA process as a team learning event; QOF significant event criteria; National Patient Safety Agency classification of significant events, and category of patient-safety incidents.

SEA in general practice is a valuable clinical governance and educational tool with potential patient safety benefits. Most practices performed SEA successfully but there were performance concerns and patient-safety issues were highlighted. This review emphasises the need for primary care organisations to be able to analyse and share SEAs effectively.