Choose significant events taking place within your practice (e.g. deaths, myocardial infarctions, admissions). Review as a practice team. What happened? Could the event have been avoided? What can the team learn? What can you learn?  What actions should you personally or the team take. Even if all was handled perfectly you may identify gaps in your knowledge (e.g. what do you know about the antiarrhthymics that you have just signed on to the patients repeat card as per the discharge summary?).

Be positive. Look for good points and plan for the future rather than looking to apportion blame.

Choose an event

·        May have affected you or the team or changed outcomes for the patient.

Choose the team

·        Ideally involve all members of the PHCT

·        Should be an opportunity for the whole PHCT to learn other.

Do not be too “Doctor-centred”   

Prepare the team

·        Write down your thoughts and recollections before the meeting. What questions or other points follow from the event?

Structure the meeting

 All main players to read out their summary sheets

·        Use flip chart.

·        Summarise what was done well and what could have been done better.

·        List other areas that follow on from this event.

Make conclusions

·        Identify individual and team learning needs.

·        Make an action plan and plan how you will evaluate it.

·        Record what happened

·        Follow up and evaluate.

Record,See the enclosed worksheet

See the University of Exeter Significant Event Website for many more resources