Improving Significant Event Analysis in Your GP Practice: A Complete Implementation Plan

This plan gives you a systematic approach to significant event analysis that goes beyond the standard "something went wrong, let's discuss it" model. You'll build an event capture system where all staff report freely, a triage process that matches investigation depth to event severity, and a governance rhythm that turns individual events into sustained practice improvement.

Most practices do SEA. Fewer do it well. The difference between a tick-box SEA and a genuinely useful one is volume and consistency: practices that discuss dozens of events a year learn faster than those that formally analyse three. This plan helps you get there, starting with the foundations and building towards a reporting culture where flagging a near-miss is as routine as checking the morning inbox.

Implementation timeframe: 8-10 weeks from kick-off to first audit cycle

Why This Matters

For Your Practice

• CQC expects it, properly: Under the Learning Culture quality statement, CQC inspectors look for six specific elements (GP Mythbuster 3): all staff can identify events, information is gathered systematically, team-based meetings analyse events, changes are agreed and implemented, written reports exist, and learning is shared across the practice. A handful of annual SEAs with "human error" as the root cause won't satisfy this.

• LFPSE is now contractual: From the 2025/26 GP contract, every practice must register with the Learn from Patient Safety Events service and use it to record patient safety events. LFPSE replaced the old NRLS (decommissioned June 2024). Your SEA process needs to feed directly into LFPSE reporting.

• PSIRF principles are the direction of travel: The Patient Safety Incident Response Framework isn't a contractual requirement for GP practices. A two-phase pilot programme tested it across 50+ primary care organisations, with results due March 2026. The 2025/26 GP contract requires practices to "have regard to" the Primary Care Patient Safety Strategy (September 2024), which is built around PSIRF's core concepts: proportionate, systems-based investigation rather than one-size-fits-all root cause analysis. The ongoing restructuring of NHS England into DHSC (target completion April 2027) creates uncertainty about the timeline for wider rollout, but the underlying principles of proportionate response and systems thinking are already embedded in what CQC expects. Building your SEA system around these principles means you're ready regardless of what the contract eventually requires.

• Near-misses are your richest learning source: Safety science consistently shows that for every event causing harm, there are many more near-misses sharing the same causal pathways. A practice that only investigates after harm has already occurred is missing the chance to prevent it. Building near-miss reporting into your SEA system gives you learning without waiting for damage.

• Volume drives improvement: Once you start capturing near-misses, your SEA volume should increase dramatically. Not because more things are going wrong, but because you're catching more of the small things before they become big ones. A cancer diagnosis coded incorrectly by the workflow team, a referral that nearly went to the wrong clinic, a repeat prescription that almost went out without a review. These are all events worth a five-minute team discussion. Individually small, collectively they prevent the serious incident that keeps you up at night.

For Your Professional Development

By leading this improvement, you'll demonstrate:

• Governance leadership: Designing and implementing a structured patient safety system that meets CQC, GMC, and national patient safety requirements, demonstrating senior operational capability

• Safety culture development: Moving the practice from reactive incident management to proactive safety learning, a genuine culture change, not just a process change

• Regulatory expertise: Navigating PSIRF, LFPSE, Duty of Candour, and CQC requirements in an integrated system

• Quality improvement: Using event data to identify themes, drive change, and measure whether improvements stick

• Supporting GP revalidation: The GMC requires doctors to declare and reflect on significant events at appraisal. A well-run SEA system with properly documented events directly supports the revalidation cycle for every GP in the practice

Add this to your year-end evaluation: "Designed and implemented a structured significant event analysis system with proportionate investigation pathways, increasing event reporting by [X]%, establishing monthly learning reviews, and achieving LFPSE reporting compliance. The system identified [specific theme] leading to [specific improvement]."

Prerequisites and Preparation

What You Need Before Starting

• Approvals: Partner agreement to protect time for regular SEA discussions (this is the non-negotiable; without protected time, nothing else works), and agreement on who triages events and who facilitates meetings

• Stakeholders: Identify your Patient Safety Lead (overall accountability, often practice manager), Clinical Lead for SEA (usually a GP partner), and an SEA Coordinator (can be practice manager, deputy, or trained administrator, whoever manages the event log and coordinates meetings)

• LFPSE access: Confirm your practice has an LFPSE administrator account registered. If not, this is now a contractual requirement. Register at the LFPSE service portal or email patientsafety.enquiries@nhs.net

• Current state: Pull your SEA data for the last 12 months. How many events were formally analysed? How many involved near-misses versus actual harm? How many staff groups contributed events? What percentage resulted in documented actions? What percentage of actions were followed up? If you can't answer these questions, that's your baseline finding.

Estimated Time Investment

• Total implementation: 8-10 weeks from kick-off to first audit

• Your time per week: 3-4 hours in weeks 1-4 (setup and design), dropping to 1-2 hours ongoing

• SEA Coordinator time: 2-3 hours per week ongoing (event log management, meeting preparation, action tracking)

• Staff training: 3-4 hours total (1 hour clinical staff, 1 hour non-clinical staff, 1-2 hours whole-team SEA practice session)

• Monthly SEA meeting: 60-90 minutes protected time

• Quick event discussions: 5-15 minutes each, as they arise (this is where the volume comes from)

The Implementation Plan

Phase 1: Kick-Off and Planning (Week 1-2)

Meeting 1: Initial Kick-Off

Attendees: Practice Manager, GP Clinical Lead, SEA Coordinator, admin supervisor, nurse lead

Duration: 60 minutes

Agenda:

1. Present the baseline. Share your 12-month SEA data. Most practices find they've done 6-12 formal SEAs, almost all triggered by harm events, with actions that were agreed but rarely followed up. If your data shows otherwise, great. This plan will help you build on that. If it shows the typical pattern, be honest about it. That honesty is the starting point.

2. Introduce the two-tier approach. Explain the distinction between quick event discussions (5-15 minutes, high volume, handled in huddles or at the end of team meetings) and formal SEA meetings (60-90 minutes, protected time, for events requiring deeper analysis). Not everything needs a full meeting. The goal is proportionate investigation, matching the depth of analysis to the significance of the event.

3. Agree protected time. Monthly SEA meetings go in the diary now, for the next 12 months. This is the single most important output from this meeting. Without it, the system will fail within three months.

4. Agree the reporting mechanism. How will staff report events? A shared inbox, a form on the intranet, a paper slip in a box, a message to the SEA Coordinator? It must be quick (under 2 minutes to submit), accessible to all staff (not just those with clinical system access), and psychologically safe (no requirement to name yourself if you'd rather not for initial reporting).

5. Set the timeline. Week 2-4: build the system and documents. Week 4-6: train staff. Week 6: go live. Week 8-10: first review and audit.

Outputs:

• Protected monthly SEA meeting slots booked for 12 months

• Named Patient Safety Lead, Clinical Lead, and SEA Coordinator

• Agreed event reporting mechanism

• Baseline data documented (however thin)

Action: Create Your Document Package

You'll need these documents to support your SEA system:

• Policy: Patient Safety Incident Response Policy, establishing your framework for identifying, reporting, investigating, and learning from patient safety events, aligned with PSIRF principles

• SOPs:

  • Significant Event Analysis SOP: the step-by-step process from event identification through analysis to action completion

  • LFPSE Reporting SOP: recording events in the national system within 2 working days

  • Patient Safety Investigation SOP: proportionate investigation methods (After Action Review, Swarm/Huddle, full systems analysis)

  • Duty of Candour Notification SOP: when and how to tell patients about safety incidents (statutory requirement for moderate harm, severe harm, and death)

• Forms:

  • Patient Safety Incident Report Form: initial event capture for all staff

  • Significant Event Analysis Form: structured analysis template for formal SEA meetings

  • Investigation Action Plan Template: SMART actions with named owners and 3/6-month review dates

• Audits:

  • SEA Process Audit Checklist: quarterly verification of event capture, investigation quality, action completion, and learning dissemination

My Practice Manager subscribers can generate these documents using the AI document tools in about a minute, or browse the compliance library for pre-built templates to customise manually.

For manual implementation: Create similar documents ensuring you address CQC Regulations 12 (safe care), 17 (good governance), and 20 (Duty of Candour), along with GMC significant event requirements for revalidation and LFPSE reporting obligations under the 2025/26 GP contract. The CQC GP Mythbuster 3 sets out the six elements inspectors expect to see.

Phase 2: Build Your Event Capture and Triage System (Week 2-4)

This is where you design the engine of your SEA system: how events get captured, how they get triaged, and what investigation each one gets.

Component 1: Event Threshold and Trigger Criteria

Define what counts as a reportable event in your practice. The GMC defines a significant event as "any unintended or unexpected event, which could or did lead to harm of one or more patients." That's deliberately broad. Your local threshold should be broader still, because you want volume. You want staff reporting things that nearly went wrong, not just things that did.

Your reportable event categories:

The test for staff: "If this event happened again tomorrow with a different patient and a different member of staff, would we want to know about it?" If yes, report it.

Component 2: Event Triage

When an event is reported, the SEA Coordinator triages it. This should happen within 2 working days of the event being reported.

Step 1: Safety screen. Does this event require immediate action? Is there an ongoing risk to patients right now? Is there a Duty of Candour trigger (moderate harm, severe harm, or death)? If yes, escalate to the Clinical Lead and Patient Safety Lead immediately. Don't wait for triage. Act.

Step 2: Grade the harm level.

Step 3: Determine the investigation response. This is where PSIRF's proportionate approach applies:

Step 4: Log everything. Every reported event goes in your event log, including those triaged as requiring only a quick discussion. This log is your evidence that you're capturing the full picture, not cherry-picking events for formal analysis. Over time, this log becomes your most valuable governance dataset.

Component 3: The Event Log

Create a central register tracking every reported event. This is the backbone of your system.

Minimum fields:

• Reference number (format: SEA-YYYY-NNN)

• Date of event

• Date reported

• Reporter (name or "anonymous")

• Brief description

• Event category (harm / near-miss / system failure / positive / complaint-related)

• Harm grade (0-4)

• Investigation response assigned (quick discussion / AAR / formal SEA / full systems analysis)

• LFPSE reported (yes/no/not applicable, with date)

• Duty of Candour triggered (yes/no, with date of notification)

• Actions agreed

• Action completion date

• 3-month effectiveness review date

• Status (open / actions in progress / closed)

A spreadsheet works. Your clinical system's event module works. The format matters less than consistency: every event, every time, no exceptions.

Meeting 2: Framework Review

Attendees: Patient Safety Lead, Clinical Lead, SEA Coordinator, GP partner

Duration: 90 minutes

Agenda:

1. Walk through the event categories and triage framework using 5-6 real past events from your practice

2. Test the harm grading: does the team agree on what constitutes grade 1 vs grade 2?

3. Review the investigation response pathways: are they proportionate and realistic?

4. Confirm the event reporting mechanism works (test it)

5. Approve documents for staff training

Outputs: Approved triage framework, calibrated harm grading, event reporting mechanism confirmed working

Phase 3: Staff Training and Communication (Week 4-6)

Action: Deliver Training

Clinical staff training (1 hour):

• The event categories and what to report (emphasis: near-misses and positive events, not just harm)

• How harm grading works and what investigation each grade triggers

• Their role in SEA meetings: contributing to analysis, not being on trial

• Systems thinking basics: when something goes wrong, the question is "what in our systems allowed this?" not "who made the mistake?" NHS England's Being Fair framework (which replaced the old Just Culture Guide) is clear: patient safety incidents are usually signs of underlying systemic issues, not individual failings

• How SEA supports their appraisal and revalidation. The GMC requires doctors to declare and reflect on significant events, and a well-documented SEA provides exactly the evidence they need

• LFPSE reporting: what gets reported nationally and why

Non-clinical staff training (1 hour):

• Why their reports matter as much as clinicians'. Receptionists and administrators spot system failures, near-misses, and workflow problems that clinicians never see

• How to report an event (demonstrate the mechanism, make them do it in the session)

• What happens after they report (their event goes in the log, gets triaged, and if it leads to a change, they'll hear about it)

• They will never be blamed for reporting. The only wrong thing to do is not report.

• Examples relevant to their role: wrong patient called, prescription sent to wrong pharmacy, patient complaint revealing a safety issue, lab result sitting unactioned, discharge letter not scanned

Whole-team SEA practice session (1-2 hours):

• Run a practice SEA meeting using a real anonymised event from your practice

• Demonstrate the facilitation approach: what happened, why, what should change, how we'll know it worked

• Practise systems thinking. Present a scenario where the "obvious" cause is human error, then explore contributing factors together. Use a fishbone diagram if it helps. The visual structure forces the team to think beyond the individual. Categories for general practice: staffing and workload, clinical systems and IT, communication, training and competency, environment, policies and procedures

• Show how the action plan works: SMART actions, named owners, specific deadlines, 3-month and 6-month review points

• Discuss psychological safety openly. Research from NHS staff surveys consistently shows that staff underreport because they fear blame or see no change from previous reports. Address both directly: reporting is expected and valued, and you will feed back what changed because of their reports

Communication timeline:

• Week 4: Clinical staff session

• Week 5: Non-clinical staff session

• Week 5-6: Whole-team practice SEA session (this is the important one, everyone together practising the process)

• Ongoing: New starter induction includes SEA module

Writing Up SEAs: Systems Thinking, Not Blame

The quality of your SEA write-ups determines whether you're genuinely learning or ticking a box. A good write-up identifies the system conditions that allowed the event to happen. A poor one says "human error" and moves on.

What a good SEA report contains:

• Factual timeline of the event (what happened, when, who was involved)

• Contributing factors identified using structured analysis (not just the immediate trigger, but the underlying conditions: was the clinician under time pressure? Was the system displaying information poorly? Was there no protocol for this situation? Was staffing below safe levels?)

• What went well (there are almost always aspects of the response that worked, so identify and reinforce them)

• Specific, measurable actions with named owners and deadlines

• How you'll know the change worked (the effectiveness measure)

What "human error" actually means: When the root cause of an SEA is recorded as "human error," you haven't finished the analysis. People make errors because systems create the conditions for errors. A GP who misses a diagnosis was working within a system: workload, time per patient, clinical system design, referral pathways, safety-netting protocols. The question is which system factors contributed, and which of those can you change.

One of the biggest barriers to high-volume SEA is the write-up itself. If it depends on one person's note-taking skills and availability, it becomes a bottleneck. You can delegate this. If you're a My Practice Manager subscriber, the SEA writer tool generates a structured report from your discussion notes in about a minute. Any team member can enter the event description, contributing factors, and actions agreed, and the output is consistent regardless of who submits it. The lead reviews and signs off, but the drafting doesn't depend on their time or writing ability.

Phase 4: Go Live and Build Momentum (Week 6-8)

Action: Launch the System

Week 1 priorities:

1. Start the event log. From day one, every reported event goes in the register. The SEA Coordinator checks the reporting mechanism daily and logs new events.

2. Triage within 2 working days. Every event gets a harm grade and investigation response assigned. The Coordinator flags anything requiring immediate escalation.

3. Quick discussions start immediately. Grade 0-1 events don't wait for the monthly meeting. Discuss them in morning huddles, at the end of clinical sessions, during team coffee breaks. Five minutes, three questions: what happened, what should we do about it, who's responsible for the action? Log it. Move on. This is where volume builds.

4. First monthly meeting. Your first formal SEA meeting happens in this phase. Use the practice session format from training. Tackle 2-3 events that warrant deeper analysis.

LFPSE reporting rhythm: Every patient safety event should be recorded in LFPSE within 2 working days. The SEA Coordinator should submit the initial report at the point of triage (you don't need to wait until the investigation is complete. LFPSE allows you to update records as your investigation progresses). This is now a contractual requirement, not optional.

Set up recurring tasks to maintain the rhythm:

• Daily: SEA Coordinator checks the event reporting mechanism and logs new events

• Within 2 working days: Triage each event (harm grade, investigation response, LFPSE submission)

• Weekly: Quick check of the event log for overdue actions and upcoming review dates

• Monthly: Formal SEA meeting (60-90 minutes, protected time, all relevant staff)

• Quarterly: SEA process audit and theme analysis

Use your existing task management system to schedule these as recurring reminders.

Key metrics to track from Week 6:

• Event reporting rate: How many events reported per month? Track by category (harm, near-miss, system failure, positive). You want to see near-misses outnumbering harm events. A ratio of 3:1 or higher suggests a healthy reporting culture. If your ratio is lower, it probably means you're underreporting near-misses, not that you're unsafe.

• Triage compliance: 100% of events triaged within 2 working days

• LFPSE compliance: All applicable events submitted within 2 working days

• Action completion rate: Target 90% of actions completed by deadline

• Reporter diversity: Are events coming from all staff groups, or only GPs? If only clinicians are reporting, your non-clinical staff training needs reinforcement.

• Time from event to discussion: Grade 0-1 events discussed within 1 week. Grade 2 events discussed at next monthly meeting. Grade 3-4 events investigated within 8 weeks.

Early warning signs:

• Only GPs reporting events (non-clinical staff don't feel safe or don't see it as their role)

• All events graded as harm (near-misses aren't being captured)

• Monthly meeting being cancelled or shortened (protected time is being eroded)

• Actions agreed but never followed up (the most common failure mode, and exactly what CQC will spot)

• Write-ups all say "human error" (systems thinking hasn't embedded)

Phase 5: Review and Embed (Month 2-3)

Monthly Learning Review Meeting

This is the meeting that turns individual events into practice improvement. It replaces ad-hoc SEA discussions with structured, evidenced governance.

Attendees: Patient Safety Lead, Clinical Lead, SEA Coordinator, clinical and non-clinical staff (rotate attendance to keep it inclusive)

Duration: 60-90 minutes

Standing agenda:

1. Volume and reporting health. How many events this month? Breakdown by category. Near-miss to harm ratio. Which staff groups are reporting?

2. Formal SEA discussion. Present 2-3 grade 2+ events for full team analysis. Use the structured approach: timeline, contributing factors (systems-based), what went well, actions.

3. Quick event round-up. Brief summary of grade 0-1 events discussed during the month. Any themes emerging?

4. Theme analysis. Step back from individual events. What patterns are you seeing across the last 3 months? Repeated near-misses in the same area? A cluster of events involving the same process?

5. Action review. Check completion of actions from previous meetings. For actions older than 3 months, assess whether the change has actually stuck. Has the same type of event recurred?

6. Feedback to reporters. What changed because of reported events this month? Share this with the whole team after the meeting. Nothing kills reporting culture faster than silence.

Outputs: Meeting minutes documenting events discussed, contributing factors identified, actions agreed (SMART, named owners, deadlines), and theme observations. This is your CQC evidence of embedded learning.

Meeting 3: First Formal Review

When: 8 weeks after go-live

Attendees: Full implementation team plus a frontline staff representative

Agenda:

1. Review metrics against targets: reporting volume, near-miss ratio, triage compliance, LFPSE submission rates, action completion

2. Assess reporting culture. Are all staff groups reporting? Is the mechanism easy enough? Are people reporting near-misses and positive events, or only harm?

3. Evaluate meeting quality. Are SEA discussions genuinely systems-based, or defaulting to blame? Are actions specific and measurable, or vague?

4. Review theme data. Even 8 weeks of structured data reveals patterns. What's your most common event category? What system is generating the most near-misses?

5. Adjust and plan. Refine any elements that aren't working. Set targets for the next quarter.

Outputs:

• Performance dashboard: reporting volume, category distribution, triage compliance, LFPSE compliance, action completion rate

• Identified themes and system improvement priorities

• Any adjustments to the triage framework or meeting format

• Evidence package: training records, meeting minutes, event log, metrics dashboard, all ready for CQC

Action: Conduct First Formal Audit

Using the SEA Process Audit Checklist:

1. Sample 10-15 events from the event log (mix of categories and harm grades)

2. Check reporting quality. Were events reported with enough information to triage? Were near-misses captured, not just harm events?

3. Verify triage. Was every event harm-graded and assigned an investigation response within 2 working days? Was the response proportionate?

4. Assess investigation quality. For formal SEA events, was the analysis systems-based? Were contributing factors identified beyond "human error"? Were actions SMART with named owners?

5. Check action completion. Were actions completed by their deadline? Were 3-month effectiveness reviews conducted? Did the change actually work?

6. Review LFPSE compliance. Were applicable events submitted within 2 working days? Were records updated as investigations progressed?

Outputs:

• Audit report with compliance percentages for each criterion

• Action plan for gaps identified

• Baseline for next quarterly audit

• Evidence for CQC inspection

Common Problems and Solutions

Problem 1: "We only do SEA when something really goes wrong"

Why this happens: The traditional model treats SEA as a formal, time-consuming process reserved for serious incidents. If every event requires a 90-minute meeting, you'll only analyse the ones you can't ignore.

How to address it: The two-tier approach is the answer. Grade 0-1 events get a 5-15 minute discussion in a huddle or at the end of a session. Only grade 2+ events go to the formal monthly meeting. This dramatically lowers the barrier to discussing events. A wrong-patient-nearly-called is worth a quick "what happened, how do we prevent it?" conversation. It doesn't need a full investigation.

Prevention: Track your event volume monthly. If you're logging fewer than 8-10 events per month in a typical practice, you're underreporting. Encourage staff to report anything that passes the test: "Would we want to know if this happened again tomorrow?"

Problem 2: "Staff don't report because they're afraid of being blamed"

Why this happens: Deep-seated. Even practices that say they have a "no blame culture" often have staff who've seen or heard of colleagues being criticised after an incident. The 2024 NHS Staff Survey found that only 68% of staff agreed their organisation takes action when errors are reported, and nearly 39% said they don't receive feedback about changes made in response.

How to address it:

1. NHS England's Being Fair framework is explicit: patient safety incidents are usually signs of underlying systemic issues. The default response is system improvement, not individual investigation. Individual accountability only applies where there's evidence of recklessness, wilful neglect, or intention to cause harm, and that's rare.

2. Allow anonymous initial reporting. Some staff will only report if they can do so without being identified. Accept that. A learning point from an anonymous report is just as valuable.

3. Visibly close the loop. When an event report leads to a change, tell the team. "Last month, a member of staff reported that discharge summaries were being filed without clinical review. We've now added a clinical review step to the workflow. Thank you to whoever reported this." That visibility is what builds trust.

4. Leaders report first. If the GP partners and practice manager are openly reporting their own near-misses and errors, it normalises reporting for everyone else.

Prevention: Monitor reporter diversity. If only GPs are reporting, your non-clinical staff don't feel safe. Address it directly in team meetings.

Problem 3: "We don't have time for proper SEA meetings"

Why this happens: Protected time gets eroded by clinical pressures. The monthly meeting gets pushed, shortened, or cancelled.

How to address it:

1. Book 12 months of meetings in advance. Treat them as non-negotiable, like flu clinic or smear clinic. They're in the diary, staff are booked out, and patients aren't booked in that slot.

2. Keep to time. 60-90 minutes, not longer. A well-facilitated meeting that covers 2-3 events in 60 minutes is more valuable than a rambling 2-hour session.

3. Rotate facilitation. Not always the senior partner. Practice managers, nurse leads, and pharmacists can all facilitate effectively. Rotating also prevents the meeting from feeling like a clinical hierarchy exercise.

4. Use the quick discussion tier for volume. The monthly meeting isn't where most learning happens. It's the daily and weekly quick discussions that build the culture. The monthly meeting handles the events that need deeper analysis.

Prevention: Track whether meetings happened, their duration, and attendance. Include this in your quarterly audit. If meetings are being cancelled, that's a governance red flag.

Problem 4: "Our write-ups always end up saying 'human error' as the root cause"

Why this happens: Without training in systems thinking, it's natural to identify the person closest to the event as the cause. "The GP didn't spot the diagnosis" feels like a complete explanation. It isn't.

How to address it:

1. Ban "human error" as a standalone root cause. It's a starting point, not an endpoint. When someone identifies human error, the facilitator's next question is always: "What in our system made that error possible or likely?"

2. Use a fishbone diagram for grade 2+ events. Draw the event at the head. Draw six bones: staffing/workload, clinical systems/IT, communication, training/competency, environment, policies/procedures. For each bone, ask: "Did anything in this category contribute?" This forces structured thinking.

3. The substitution test. "Would another competent person in the same situation, with the same information, under the same pressures, have done the same thing?" If the answer is yes (and it usually is), the cause is systemic, not individual.

Prevention: Include a systems thinking refresher in your annual SEA training. Share NHS England's Being Fair framework with the team. It explicitly moves away from blame-based investigation.

Problem 5: "We do the SEA but nothing actually changes afterwards"

Why this happens: Actions are agreed in the meeting but nobody tracks them. Three months later, the same type of event recurs. This is the most common SEA failure mode and exactly what CQC will identify.

How to address it:

1. Every action must be SMART: specific, measurable, achievable, relevant, time-bound. "Improve communication" is not an action. "Add a mandatory free-text field to the triage template for red flag symptoms, implemented by [name] by [date]" is.

2. Every action has a named owner. Not "the team". One person.

3. Every action has a 3-month effectiveness review. Not just "was it done?" but "did it work?" Has the same type of event recurred? If you changed a process, is the new process actually being followed?

4. Review overdue actions at every monthly meeting. It's a standing agenda item. If an action is consistently overdue, it was either unrealistic or unimportant. Either way, address it.

Prevention: Set up deadline reminders for every action and every 3-month review. Automate the nagging so it doesn't depend on someone remembering.

Success Criteria and Evidence

You'll Know You've Succeeded When:

• Event reporting volume has increased: A typical practice should be logging 8-15+ events per month across all categories, with near-misses outnumbering harm events

• All staff groups are reporting: Events coming from receptionists, administrators, nurses, pharmacists, and GPs, not just clinicians

• 100% triage compliance: Every event harm-graded and assigned an investigation response within 2 working days

• LFPSE compliance: All applicable events submitted within 2 working days, with records updated as investigations progress

• Monthly meetings happening: Protected time, documented minutes, systems-based analysis, SMART actions with named owners

• Actions are completed and reviewed: 90%+ action completion rate, with 3-month effectiveness reviews showing changes have stuck

• Theme analysis is driving improvement: Quarterly patterns identified, systemic changes implemented, repeat events reducing

• Staff report confidently: Team members describe the system as fair and useful, not burdensome or punitive

Evidence You Can Show to CQC:

Documentation:

• Approved Patient Safety Incident Response Policy with PSIRF alignment

• SEA, LFPSE reporting, investigation, and Duty of Candour SOPs with version control

• Event log showing all reported events with triage decisions, investigation outcomes, and action tracking

• SEA meeting minutes demonstrating systems-based analysis and learning

Data and trends:

• 12-month event reporting dashboard: volume by category, harm grade distribution, near-miss ratio

• Triage compliance rates (monthly)

• LFPSE submission compliance (monthly)

• Action completion rates with effectiveness review outcomes

• Theme analysis showing patterns identified and addressed

Governance evidence:

• Monthly SEA meeting minutes with documented actions and named owners

• Quarterly audit reports with compliance scores and improvement plans

• Annual review of Patient Safety Incident Response Plan

• Cross-referencing with complaints, clinical audit, and safeguarding data

Staff and culture evidence:

• Training records for all staff (initial and annual refresher)

• Reporter diversity data showing all staff groups contributing

• Evidence of feedback to reporters (what changed because of their reports)

• Staff who can describe the reporting process and explain what happens after they report

Maintaining the Improvement

Daily/weekly activities (2-3 hours):

• Event monitoring: SEA Coordinator checks reporting mechanism, logs events, triages within 2 working days

• Quick discussions: Grade 0-1 events discussed in huddles or at the end of sessions. Logged with brief learning point.

• LFPSE submission: Applicable events submitted within 2 working days of triage

• Action tracking: Weekly check for overdue actions and approaching deadlines

Monthly activities (3-4 hours):

• Formal SEA meeting: 60-90 minutes, protected time. 2-3 grade 2+ events for systems-based analysis. Quick event round-up. Action review. Theme observations.

• Feedback to team: Share what changed because of reported events. Celebrate positive events and good catches.

• Metrics review: Reporting volume, near-miss ratio, triage compliance, action completion. Flag anything below target.

Quarterly activities (3-4 hours):

• SEA process audit: Sample 10-15 events, verify triage quality, check investigation depth, review action completion and effectiveness

• Theme analysis: What patterns are emerging across the quarter? Are the same types of events recurring? What systemic changes are needed?

• Partner report: Brief dashboard for partners showing reporting volume, themes, actions, and learning outcomes

Annual activities (4-6 hours):

• Policy review: Full review of Patient Safety Incident Response Policy and all supporting SOPs. Update for regulatory changes. Partner sign-off.

• Patient Safety Incident Response Plan (PSIRP) review: Review your priority safety areas for the coming year based on event data, national alerts, and local intelligence

• Refresher training: All staff complete annual SEA training, including systems thinking refresher and any procedure changes

• 12-month analysis: Comprehensive review of event data, themes, actions, and outcomes. What improved? What persists? What's the plan for next year?

• Appraisal support: Ensure all GPs have access to their SEA participation records for annual appraisal and revalidation

Building the volume: The real measure of success isn't the formal monthly meeting. It's the quick discussions that happen daily and weekly. A cancer diagnosis coded correctly because the workflow team has learned from previous coding events. A near-miss caught and fixed in five minutes. A receptionist flagging that the same issue has happened three times this week. When staff are raising and resolving small events routinely, you've built a learning culture. The formal system exists to capture it, track it, and prove it to CQC.

Additional Resources

My Practice Manager Tools

SEA Writer: Enter your discussion notes and get a structured SEA report in about a minute. Consistent quality regardless of who submits it, so you can delegate write-ups to less senior staff without the output suffering.

AI Document Tools: Generate patient safety policies, investigation templates, and other compliance documents.

Compliance Library: Patient safety, clinical governance, and Duty of Candour templates with regulatory citations and CQC mappings.

Related Improvement Plans

Related improvement plans covering complementary clinical governance, patient safety, and quality improvement topics are in development.

Regulatory Guidance and Standards

• CQC GP Mythbuster 3: Significant Event Analysis. The six elements CQC inspectors expect to see

• CQC GP Mythbuster 24: Recording Patient Safety Events in LFPSE. What to record and how

• CQC Learning Culture Quality Statement. What "good" looks like for safety culture

• NHS England: Primary Care Patient Safety Strategy (September 2024). National direction for primary care safety improvement

• NHS England: Patient Safety Incident Response Framework (PSIRF). The framework being piloted in general practice

• NHS England: Being Fair Tool. Replaces the Just Culture Guide. How to respond fairly when incidents raise individual conduct concerns

• NHS England: Learn from Patient Safety Events (LFPSE). National reporting system and GP practice registration

• GMC: Significant Events: Guidance on Supporting Information for Revalidation. What GPs must declare at appraisal

• NHS Resolution: Just and Learning Culture Charter. Principles for a fair and learning-focused response to incidents

• RCGP Patient Safety Toolkit: Significant Event Audit. RCGP guidance on SEA best practice

This improvement plan is provided as practical guidance for GP practice managers implementing structured significant event analysis systems. While based on current regulatory requirements (CQC Regulations 12, 17, and 20; GMC revalidation requirements; LFPSE contractual obligations under the 2025/26 GP contract; PSIRF principles), you should exercise professional judgment and adapt recommendations to your practice's specific circumstances and reporting volumes. The CQC assessment framework is undergoing revision, with a GP-specific inspection framework expected in 2026. NHS England is being restructured into DHSC (target April 2027), which may affect the timeline for some patient safety initiatives referenced here. For clinical or legal advice, consult appropriate professionals.