ArticleThe British journal of general practice : the journal of the Royal College of General Practitioners2007
A retrospective review of significant events reported in one district in 2004-2005.
Article in The British journal of general practice : the journal of the Royal College of General Practitioners, 2007. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
9 citing papers in PubMed.
- Final-year medical students' reflections on types of significant events in primary care.African journal of primary health care & family medicine · 2023Article
- Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.Therapeutic advances in drug safety · 2023Article
- Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.BMJ quality & safety · 2021Article
- Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice.The British journal of general practice : the journal of the Royal College of General Practitioners · 2018Article
- Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care.The Journal of continuing education in the health professions · 2016Article
- Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care.The European journal of general practice · 2015Article
- Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method.BMC family practice · 2014Article
- Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports.The British journal of general practice : the journal of the Royal College of General Practitioners · 2013Article
- A review of significant events analysed in general practice: implications for the quality and safety of patient care.BMC family practice · 2009Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
2 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundPatient 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.
aimTo review SEAs submitted for the QOF by general practices for a primary care trust (PCT) in 2004-2005. DESIGN OF STUDY: A retrospective review of SEAs.
settingSt Helens PCT, Merseyside, North West England, UK (185 000 patients), now part of Halton and St Helens PCT.
methodThree 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).
resultsPractices 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.
conclusionSEA 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.
Indexed as
Identifiers
17891868PMC2151788What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.