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National Patient Safety Agency

New guidance launched to improve patient safety in General Practice

02 October 2008



Today, Thursday 2 October, The National Patient Safety Agency (NPSA) will launch new guidance for general practice teams enabling them to learn from patient safety incidents and “near misses”.  The new Significant Event Audit (SEA) guidance aims to improve the quality and safety of patient care in general practice.


Significant Event Audit (SEA) was established in the mid 1990s as an effective quality assurance method in general practice with the aim of improving patients’ experience, care and outcomes and to identify changes that might improve future care.  These episodes could include a wrongly administered MMR vaccination or wrongly prescribed medication.


SEA was incorporated into the Quality and Outcomes Framework in 2004, as part of the new General Medical Services contract requirements.  An initial scoping exercise by the NPSA found that the quality of SEAs conducted was variable and could be improved.  This new guidance aims to raise awareness of how to conduct an SEA in seven simple stages so that general practice teams can learn and improve the quality of patient care.


In collaboration with Professor Mike Pringle, Division of Primary Care, University of Nottingham, and NHS Education for Scotland (NES) with support from the Royal College of General Practitioners and Quality Improvement Scotland, the NPSA has published the SEA guidance for primary care teams in the UK.  


Speaking about the guidance, Professor Mike Pringle, University of Nottingham, said: “SEA is an established and effective quality assurance method in general practice.  It helps to improve patients’ experience, care and outcomes by facilitating learning from experience and will be part of GP revalidation.  This guidance will help encourage and inform existing and new users of SEA.”


Dr Paul Bowie, Associate Adviser, NES, added: “The guidance will act as a key educational resource for many primary care teams, enabling them to undertake much more effective SEA.  This will further enhance team-based learning and lead to greater opportunities to improve the quality and safety of health care.  NES is delighted to contribute to the development of this guidance and will be active in promoting its use throughout NHS Scotland”.


Joanna Parker, Head of Primary Care, NPSA, said: “The NPSA is delighted to support the publication of this SEA guidance.  It provides a clear, structured approach to help general practice teams turn SEA into a routine team learning activity to the benefit of all their patients and with potential to share that learning across the service.”


Dr Maureen Baker, Honorary Secretary of the RCGP, said: “SEA is a learning technique that GPs and practice teams are already familiar with. The guidance will help practices improve their use of SEA and lead to greater incident reporting in general practice.”






Notes for editors:


Media enquiries to Amelia Lyons in the NPSA Communications Department on 020 7927 9580 amelia.lyons@npsa.nhs.uk.


The National Patient Safety Agency encompasses the National Research Ethics Service, National Reporting and Learning Service and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.