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Domain 2: Review of Significant Events

Domain 2: Review of Significant Events

Significant Events Analysis (SEA) is a method of reflective learning which can be used to analyse episodes of care which would benefit from further review and reflection and can inform and develop future practice. SEAs are commonly used to analyse incidents where patients experience unintentional harm - or could have been harmed - as part of the care process.  However, the SEA process can also be used to effectively analyse examples of high quality care that can influence service provision.

The numbers of significant events or serious incidents may vary across different specialties. If you have not been involved in any significant events or serious incidents you must declare this fact. You should either reflect on your local significant event or serious incident process or what you have been doing well to mitigate the risk of an event or incident occurring.

Where appropriate you can also complete a reflective template relating to specific uploaded documents, groups of documents, or any other additional information or reflections.

For appraisal purposes an SEA needs to have involved the doctor in some way. There must also be scope for the doctor to reflect on what happened with the appraiser and to consider what changes they might make for the future.

Many Sessional and Out Of Hours doctors are also involved in SEA meetings, either in collaboration with the employer or in a small study group setting.

Questions that you should address:

What happened?

Describe what actually happened in detail and chronological order. Consider, for instance, how it happened, where it happened, who was involved and what the impact or potential impact was on the patient, the team, organisation and/or others.

Why did it happen?

Describe the main and underlying reasons - both positive and negative - contributing to why the event happened. Consider, for instance, the professionalism of the team, the lack of a system or a failing in a system, lack of knowledge or the complexity and uncertainty associated with the event.

What has been learned?

Demonstrate that reflection and learning have taken place on an individual or team basis and that relevant team members have been involved in the analysis of the event. Consider, for instance: a lack of education & training; the need to follow systems or procedures; the vital importance of team working or effective communication.

What has been changed?

Outline the action(s) agreed and implemented where this is relevant or feasible. Consider, for instance, if a protocol has been amended, updated or introduced; how was this done and who was involved; how will this change or be monitored. It is also good practice to attach any documentary evidence of change (e.g. a letter of apology to a patient, or a new protocol).

Remember, the SEA process may also be used to review a very positive event - for example good teamwork in an emergency or a review of a "good death" in a terminal care situation.

Other resources:

Further help is available at NES CPD Connect website.  The direct link is:

NES has developed an Enhanced SEA which is available on Turas Learn:

There are a variety of alternative templates and resources which you may find helpful.  Please see list below.

Examples of "SEA" QIA

Related Documents

Seven Practical Steps For SEA

This document includes case studies, and dummy sample SEA report.

Date updated: 26/04/2021

Size: 150016 - KB

Type: doc

SEA - Report template (blank)

This Peer Review feedback tool for SEA reports was developed by NES, and is used by the NES Peer Review Audit and SEA Group. For more information please visit NES website. (Please note that the form must be opened via Internet Explorer, or download the PDF onto computer before opening.)

Date updated: 26/04/2021

Size: 1256614 - KB

Type: pdf

SEA - Peer Review feedback form (blank)

This Peer Review feedback tool for SEA reports was developed by NES, and is used by the NES Peer Review Audit and SEA Group. For more information please visit NES website.

Date updated: 26/04/2021

Size: 1556480 - KB

Type: doc

Learning from Significant Events

Paul Bowie, PhD, associate adviser in postgraduate GP education, NHS Education for Scotland, Glasgow - Bowie P. Learning from significant events. Practice Nurse 2010; 39(12): 11-5

Date updated: 26/04/2021

Size: 189646 - KB

Type: pdf


Document designed for electronic completion

Date updated: 26/04/2021

Size: 95744 - KB

Type: doc

This page was last updated on: 08/03/2022