ArticleBMC family practice2009
A review of significant events analysed in general practice: implications for the quality and safety of patient care.
Article in BMC family practice, 2009. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 22 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.
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Who cites it
22 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
- The Use of Radio and Telemedicine by TMAS Centers in Provision of Medical Care to Seafarers: A Systematic Review.Journal of personalized medicine · 2023Review
- Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.BMJ quality & safety · 2021Article
- User redesign, testing and evaluation of the Monitoring Risk and Improving System Safety (MoRISS) checklist for the general practice work environment.BMJ open quality · 2020Article
- Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation.BMJ open · 2020Article
- 'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice.BMC family practice · 2018Article
- Content analysis of 50 clinical negligence claims involving test results management systems in general practice.BMJ open quality · 2018Article
- Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study.BMJ open · 2017Article
- Article
- Risk Assessment of Using Entonox for the Relief of Labor Pain: A Healthcare Failure Modes and Effects Analysis Approach.Electronic physician · 2016Article
- Article
- 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
- Article
- Good practice statements on safe laboratory testing: A mixed methods study by the LINNEAUS collaboration on patient safety in primary care.The European journal of general practice · 2015Article
- 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
- Participatory design of a preliminary safety checklist for general practice.The British journal of general practice : the journal of the Royal College of General Practitioners · 2015Article
- The role of primary care in cancer diagnosis via emergency presentation: qualitative synthesis of significant event reports.British journal of cancer · 2015Article
- Patient safety skills in primary care: a national survey of GP educators.BMC family practice · 2014Article
- Article
- Organisational targets of patient safety improvement programs in primary care; an international web-based survey.BMC family practice · 2013Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundSignificant event analysis (SEA) is promoted as a team-based approach to enhancing patient safety through reflective learning. Evidence of SEA participation is required for appraisal and contractual purposes in UK general practice. A voluntary educational model in the west of Scotland enables general practitioners (GPs) and doctors-in-training to submit SEA reports for feedback from trained peers. We reviewed reports to identify the range of safety issues analysed, learning needs raised and actions taken by GP teams.
methodContent analysis of SEA reports submitted in an 18 month period between 2005 and 2007.
results191 SEA reports were reviewed. 48 described patient harm (25.1%). A further 109 reports (57.1%) outlined circumstances that had the potential to cause patient harm. Individual 'error' was cited as the most common reason for event occurrence (32.5%). Learning opportunities were identified in 182 reports (95.3%) but were often non-specific professional issues not shared with the wider practice team. 154 SEA reports (80.1%) described actions taken to improve practice systems or professional behaviour. However, non-medical staff were less likely to be involved in the changes resulting from event analyses describing patient harm (p < 0.05)
conclusionThe study provides some evidence of the potential of SEA to improve healthcare quality and safety. If applied rigorously, GP teams and doctors in training can use the technique to investigate and learn from a wide variety of quality issues including those resulting in patient harm. This leads to reported change but it is unclear if such improvement is sustained.
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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.