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Pharmacy Significant Event Analysis: Promoting Learning and Reflection

This educational development aims to advise on the process of analyzing significant events in pharmacy to foster learning and reflection within the team. Learn from positive and negative events to ensure patient safety and share good practices.

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Pharmacy Significant Event Analysis: Promoting Learning and Reflection

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  1. Pharmacy Significant Event Analysis Fiona McMillan Lead Pharmacist Educational Development Educational Solutions for Workforce Development

  2. Aim To advise on development of a process for the analysis of Significant Events to promote learning and reflection within your team

  3. ‘To err is human, to cover up is unforgivable and to fail to learn is inexcusable’’ Liam Donaldson 2004

  4. Background • SEA embedded medical model • Effective analysis allows reflection and learning within the team • Positive and negative events • Safe and effective medicines management needs systems to ensure that patient safety is maintained. • Sharing practice aids development of good practice.

  5. What is a Significant Event? Pharmacy “Any event thought by anyone in the health care team to be significant in the care of patients or the conduct of the practice or organisation.’ Pringle et al, 1995 Educational Solutions for Workforce Development

  6. Examples of Significant Events

  7. What is the process for analysis and receiving peer comments?

  8. Questions in SEA form What happened? Give adequate detail to enable reviewers to understand the whole picture Why did it happen? Explain reasons from your analysis What have you learned? Can be a list What have you changed? Will this prevent reoccurrence

  9. Benefits of SEA

  10. How could you integrate this into your practice? Pharmacy • What benefits do you see? • What are your next steps? Educational Solutions for Workforce Development

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