Reflecting on significant events during GP training

Significant event analysis should form part of your learning log during GP training. Dr Prashini Naidoo explains how to record significant events and how they will be assessed by your trainer.

Significant event audit/analysis (SEA) has become a routine part of general practice. When you have completed your training, SEA is an important part of revalidation and at least two SEAs or case reviews should form part of your annual appraisal.

During training, significant events (SE) can be recorded as part of your learning log. This article provides guidance on how to write SEs as log entries and discusses how these reflective accounts are assessed by trainers. An example of a SE learning log is provided, followed by an in-depth assessment.

By the end of this article, the trainee should be able to correctly identify what constitutes a SE; be open and self critical in their reflections; be capable of examining the underlying systems in which they work; and sum up what was learnt from the event.

Example of a significant event learning log

Subject title: Delay in referring a patient to a consultant from primary care

What happened?
I called a patient into my duty doctor clinic. From her medical record, I noticed that she had seen a different doctor on 20 June to obtain a ‘covering letter’ for her referral to the genetics clinic. The patient had seen me for this referral on 29 April.

After taking her history and agreeing that a genetics opinion was warranted, I had printed off the family history proforma for the patient to complete and post to the genetics clinic. I assumed that this was all that was needed.

When the patient didn't receive her appointment, one of our administrative staff called the clinic only to be told that the referral would not be accepted without a covering letter. Unfortunately, the hospital didn't let us know they had turned down the referral until the practice contacted them.

What issues were raised by this significant event?
The patient waited longer than expected for her appointment at the genetics clinic. The family history proforma (without a covering letter) does not contain the practice's administrative details - site code/care pathway etc.

What was done well?

  • The patient contacted our practice's administrative team – we were accessible and approachable.
  • The admin team contacted the clinic and when informed of the reason for the patient's delay in being seen, made the patient an appointment with a GP to obtain a covering letter.
  • The practice apologised to the patient for the delay and the patient did not harbour any grievance against the practice.

What was not done well?

  • I was unaware of a covering letter being needed.
  • The genetics proforma was not updated (unlike the practice's 2 week wait proforma) with the  admin details the hospital appointments team now request.
  • The practice's admin team did not inform me of my error, nor did they raise it as a significant event.  

What could be done differently in future?

  • When processes change, such as when proforma need updating with new administrative details, the office manager may want to delegate a named person to update all the computerised forms and get rid of outdated paper copies.
  • I would like to know if the referrals clerk could be more proactive about chasing up appointments for patients who are waiting for a long periods for hospital appointments, especially those that are not booked on Choose and Book.
  • The hospital appointments clerk could email us informing us of rejected referrals and the reasons for rejection.

What further (personal) learning needs did you identify?
I was concerned about not being informed of my error and the patient being booked to see a different doctor for a covering letter. Was I unapproachable or no longer trusted?

When I spoke to the admin team, they told me I was on annual leave when the patient returned. I felt a bit reassured that neither the admin team nor the patient had deliberately chosen a different clinician.

When I emailed a SEA form to the practice manager, he asked me if I wanted to be involved in the root cause analysis (RCA), a process which is unfamiliar to me.

How and when will you address these?
I found an online resource to address my learning need regarding RCA:  http://www.nrls.npsa.nhs.uk/resources/collections/root-cause-analysis/. I intend to read this and perhaps discuss this in a tutorial about clinical governance.

Shared?
Yes

Assessing a significant event analysis (SEA) learning log

In the above learning log, what medical knowledge did the trainee demonstrate?
The trainee demonstrated an understanding of what a significant event is, in that he was able to identify that a delayed patient referral, because it may have led to an undesirable outcome, constituted a SE. He was also willing to engage in this process to change things, to improve patient safety and care.

What cognitive skills did the trainee demonstrate?

1. How well did the trainee look at what was going on beneath the surface?
The trainee looked at practice referral processes. He identified why the family history proforma was rejected. He looked at the referral process for appointments that are made outside the Choose and Book system and possible pitfalls. He looked at reasons why the error was not communicated back to him. His emphasis was on examining underlying systems, rather than directing inappropriate blame at individuals.

2. Did the trainee apply theory to practice?
The trainee wrote factually and objectively, as befits a SEA write-up. He described what actually happened, the roles of all involved and the setting in which the event occurred. He considered the underlying reasons why the event happened. The data presented was anonymised.

3. What did the trainee find when he revisited the case with the new information (analysis)?
He found that several administrative processes need fine tuning, such as how we update referral forms, how we chase up non-Choose and Book referrals, how the hospital informs us of rejected referrals.

4. How well did the trainee apply new ideas to his thinking?
He considered whether there were communication issues within the practice, that is, barriers to preventing errors from being openly discussed, possibly prevently the person and practice from learning from events, from changing processes and potentially duplicating errors.

5. Finally, how well did the trainee develop his own practice (critical evaluation)?
The trainee could have described in greater detail the impact or potential impact of the event. He could have reflected more openly on his feelings. However, he clearly learnt from the event and was keen that the entire practice learn from his near-miss. He showed awareness of team roles and while he made suggestions about improving administrative procedures, he was not dictatorial.

How well did the trainee select, organise and present his learning?
The trainee selected an appropriate case for SEA, organised his thoughts logically and presented the information succinctly, all of which are useful communication skills for GPs.

Trainer feedback
What I liked about this reflective account was its personal nature. The trainee felt comfortable to openly explore his own shortcomings. He also voiced his speculation about why the patient saw a different GP, hinting to his vulnerability. He described and analysed the event well.

He identified an appropriate and important learning need, as well as a good learning resource. This should be uploaded into his PDP. I would have liked to know if (and how) he brought the matter up with the patient and the effect (if any) on the therapeutic relationship. Is there any literature on how doctors and patients learn to trust each other again after a doctor's mistake?

  • Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.

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