Part of a Practice Manager’s remit is to record Significant or Critical Events in order to encourage good practice and prevent such events from happening again. However, Significant and Critical are two separate things and one has to decide whether an event is approaching, or has reached a catastrophic or dangerous level.

To illustrate the difference, you could consider the start of WW2 as a significant event and the bombing of Hiroshima as a critical event.

So an example could be – a printer running out of ink and paper midway through the morning consultation and a clinical letter scanned into the wrong patient’s notes. Which is more serious and should either event be the subject of a significant events review? And does either affect the safe running of the practice?

Who Takes the Blame?

The question to be asked when something goes wrong is – was it human error? If an aircraft crashes, is it the pilot’s fault or a mechanical fault? If the systems went wrong is it the fault of the designer or the person who maintains the systems? When there is a possibility that someone has made a terrible mistake and may be called to account for it, there may be reluctance to record any criticism of a colleague who might have to carry the blame for the event.

Is it a Measure of Degree?

Over time one comes across events that are, or could be considered as, significant events. For instance:

• A patient is given a flu jab twice.
• Computer records of consultations are not kept in detail by practice nurses (no coding).
• A referral for possible cancer has not been made within a fortnight.
• A doctor batches referrals fortnightly resulting in complaints.
• A requested home visit was not made.
• An on-call doctor was at prayers when he should be available for telephone consultations.
• Patients complain the phone line is constantly engaged or no daily appointments are available.
• Night-time answering service not switched on.
• An oxygen cylinder is found empty when required for an emergency.
• A patient died at surgery despite resuscitation attempts.
• A patient died whilst waiting more than 2 hours for a home visit.

Significant Events Review

Those are just a few examples of incidents which can cause concern. Whatever it is needs to be investigated and presented in a standard format report for consideration at a practice meeting. Any personnel cited in the report should be present and the subject discussed in a factual way without pointing fingers, however difficult this may be. If any matters come to light during an investigation which require disciplinary action then that should take place before any significant event meeting.

Conclusion

A well-run practice may have very few serious events and so to avoid any pointless running around trying to find events to report on perhaps a Significant Events Procedure should be utilised only when something serious, significant or critical to the safe running of the practice has actually occurred.

Over to You

It is clear from recent comments that managers do sometimes find it difficult to know what to investigate. Why not add your comments by giving a list of events (say 10) that your practice has recorded as significant. A list of topics can then be kept in the Resources Section for reference.