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Table 4 Type, range and number of learning issues identified from 191 SEA reports submitted

From: A review of significant events analysed in general practice: implications for the quality and safety of patient care

Learning Issues identified n %
Personal Awareness/Responsibilities and Change
(e.g. general issues on improving diagnosis and management, dealing with negative patient/family behaviour)
98 51.3
Communication (e.g. issues on communication with patient, issues on communication within team) 54 28.3
(e.g. need for new/improved protocols/systems, staff training required)
36 18.9
Clinical Knowledge
(e.g. psychiatry, contraception)
30 15.7
Equipment/task aids/workspace
(e.g. become familiar with medical centre - whereabouts of drugs and equipment, the need to secure and check prescription pads)
26 13.6
Case Notes (e.g. the need for accurate detailed documentation, Read clinical notes) 17 8.9
Whole Practice Awareness
(e.g. need for system to respond to emergency within practice, clarification of responsibilities)
16 8.4
(e.g. responsibilities for GP-secondary care interface prescribing, need for better supervision of PRHO prescribing)
9 4.7
(e.g. effects of mental illness on carers, education required on self-management of asthma)
6 3.1
(e.g. dealing with complaints system, avoiding complaints being generated)
4 2.1
GP and Partners Awareness
(e.g. the need for regular medication review with GPs, the importance of efficient and accurate results handling system)
4 2.1
Health and Safety
(e.g. re-sheathing needles should not be undertaken, to ensure all clinical staff immunised against Hepatitis B)
3 1.6
  1. • 182 reports detailed at least one learning issue
  2. • More than one learning point may have been reported in a single report.