1. Purpose
This policy sets out how the Practice records, reviews, learns from and closes significant event analysis records in primary care.
The Verivius platform calls these records incidents. Primary-care convention often calls the review process significant event analysis or SEA. This policy uses both terms so staff understand the mapping.
2. Sources to verify before adoption
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17: https://www.legislation.gov.uk/uksi/2014/2936/regulation/17
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: https://www.legislation.gov.uk/uksi/2014/2936/regulation/20
- CQC GP mythbuster 3, Significant event analysis: https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-3-significant-event-analysis-sea
- CQC GP mythbuster 24, Recording patient safety events and learning from patient safety events: https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-24-recording-patient-safety-events-learn-patient-safety-events
- NHS England, Learn from patient safety events service, primary care information: https://www.england.nhs.uk/patient-safety/patient-safety-insight/learning-from-patient-safety-events/learn-from-patient-safety-events-service/primary-care-information/
- GMC, Good medical practice: https://www.gmc-uk.org/professional-standards/good-medical-practice-2024
3. Scope
This policy applies to:
- clinical incidents and near misses
- significant event analysis records
- prescribing, referral, communication, result-handling and safeguarding events
- complaints that identify a patient-safety learning point
- events involving GP partners, salaried GPs, locum GPs, nurses, pharmacists, healthcare assistants, reception staff and managers
- private GP services and NHS-contracted GP services where the Practice provides them
The Practice records the event once and uses the SEA process to review it.
4. SEA cycle
The Practice follows a documented SEA cycle for every event that meets the local review threshold.
4.1 Log the event
Staff record the event as soon as practicable after they become aware of it.
The record includes:
- what happened
- date and time
- patient involved where relevant
- staff involved
- immediate action taken
- known harm or risk of harm
- whether urgent escalation is needed
- whether duty of candour may apply
- whether external reporting may be needed
Staff record facts and avoid blame language.
4.2 Triage the event
The Clinical Lead or delegated senior person triages the record.
Triage considers:
- severity
- likelihood of repeat
- actual or potential harm
- patient-safety risk
- safeguarding risk
- complaint link
- data-protection link
- staff support needs
- external notification or reporting routes
The triage decision records whether the event needs immediate action, full SEA discussion or closure with documented learning.
4.3 Review the event
The SEA review identifies what happened and why.
The review considers:
- timeline
- staff account
- patient account where appropriate
- relevant records
- protocols in place at the time
- workload, staffing and communication factors
- prescribing, referral or result-handling factors
- whether the event was isolated or part of a pattern
- whether the Practice needs external advice
The review records contributing factors, learning and actions.
4.4 Close the event
The Clinical Lead closes the SEA record only when:
- immediate safety action is complete
- learning has been agreed
- improvement actions have owners
- patient or family communication has been considered
- duty of candour has been considered
- external reporting has been completed or ruled out
- the governance group has reviewed the record where required
The closure note records the reason for closure and any remaining monitoring.
5. SEA meeting cadence
The Practice uses a quarterly SEA review meeting as the Verivius default unless current CQC, NHS England, GMC, contract or local governance source material requires a different rhythm.
The meeting:
- reviews open SEA records
- reviews closed SEA records from the quarter
- checks overdue actions
- identifies repeat themes
- checks whether learning was shared with staff
- agrees whether a clinical audit or policy change is needed
- records attendance and decisions
The Practice does not describe the quarterly cadence as regulator-mandated unless the current source says so.
6. Learning loop
The Practice shares SEA learning in a way that matches the risk and audience.
Learning may be shared through:
- clinical meeting
- staff meeting
- reception-team briefing
- prescribing meeting
- safeguarding supervision
- one-to-one staff support
- policy update
- clinical audit
- patient-facing communication where appropriate
The Practice checks whether learning has changed practice. Learning is not complete until the action has been implemented and reviewed.
7. Responsibilities
- Registered Manager: owns this policy, ensures the SEA process is governed and signs off annual review.
- Clinical Lead: owns day-to-day SEA quality, triage, review standards and closure decisions.
- Lead GP or GP Partner: reviews doctor-only clinical judgement, prescribing and referral events where needed.
- Practice Manager: supports records, meeting agendas, action tracking and staff communication.
- All staff: record events promptly, take immediate safety action within role and contribute honestly to review.
8. Recording requirements
The Practice keeps the following records:
- incident or SEA record
- triage decision
- review notes
- patient communication record
- duty of candour assessment
- external reporting decision
- improvement actions
- action completion evidence
- SEA meeting minutes
- learning shared with staff
- audit record
Records are kept in the Practice governance records and are available for internal review, CQC review and external review where required.
9. Audit cadence
The Practice uses the following Verivius default audit rhythm unless current source material requires more frequent review:
- Monthly: the Clinical Lead reviews open SEA records, overdue triage and urgent actions.
- Quarterly: the SEA meeting reviews records, themes, learning and action closure.
- Annually: the Registered Manager audits the SEA process against this policy, CQC source material and GMC source material.
Audit findings are recorded as improvement actions with an owner and review date.
10. Version control and review date
The Practice keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- Incident register
- SEA meeting minutes
- Improvement action register
- Complaints policy
- Duty of candour policy
- Safeguarding policy
- Prescribing policy
- Patient data and information governance policy
- Clinical audit schedule
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.