Significant events and Swiss cheese

16th October 2017 by Sara Chambers

Significant events and Swiss cheese

There is a scientific discipline called human factors and ergonomics (HF&E) which recognises the absolute certainty that human beings will make mistakes, and so seeks to design working systems and environments that work around our human nature to reduce the risk of error as far as possible.

Many safety-critical industries like aviation have wholeheartedly adopted HF&E engineering to protect their workforce and service-users from errors. When there is a significant event, the immediate assumption is that there must be a fault somewhere in the system that allowed gaps in the layers of error protection to align and allow a mistake to slip through – rather like the holes in layers of swiss cheese suddenly all lining up (get it?!)

Does any of this sound like what happens in the healthcare system? There is some talk of no-blame investigations and developing a culture of protecting whistleblowers. But in the midst of a locum session, where no induction in practice protocols has been made available, trying to see complex patients in 10 minute appointment slots, dealing with missing results and clinic letters and coping with repeated interruptions for queries from practice staff, it feels like primary care is light years behind being an ideal safe environment.

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Related FAQs

How do I record a significant event analysis (SEA)?

Use one of our AppraisalAid forms – take your pick form any of the following that best suit the scenario – and then put your SEA in the quality improvement area of your appraisal toolkit.

Recording significant events – Standard

Recording significant events – Enhanced

Individual case review

Recording significant events – Standard

NASGP is committed to the system learning based approach to any form of adverse event, so a ‘standard’ event would be a situation you’ve come across that hasn’t lead to a serious untoward event. Just grabbed a new tube of dipsticks and spotted it’s two years past its ‘use by’ date (true story)? Then use one of these forms.

SEA – Recording significant events – Standard

Download – Word Save as – Google Doc

If you have been involved in a serious significant event that caused harm, or had the potential to cause harm, consider also looking at Recording significant events – Enhanced.

See also

Significant events and Swiss cheese

Recording significant events – Enhanced

If you have been involved in a serious significant event that caused harm, or had the potential to cause harm, you may find the process of enhanced significant event analysis helpful.

‘Significant event analysis’ here is different from a ‘significant event’ for the purposes of appraisal and revalidation; this is the name given to this very enlightened and useful form of incident analysis by its developers at NHS Education for Scotland and the Health Foundation.’

SEA – Enhanced significant event analysis

Download – Word Save as – Google Docs

If you have come across something that hasn’t yet led to any harm, try using our other AppraisalAid SEA ‘Standard’ template.

See also

Significant events and Swiss cheese

Appraisal during Covid 19

Now that appraisals are back, we’ve adapted AoMRC’s helpful pdf guide into a Google Doc and Word template.

Download – Word Save as – Google Doc

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