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P81 Significant event analysis in a hospice setting
  1. Amanda Gregory and
  2. Laura Myers
  1. St Catherine’s Hospice, Crawley, UK


Monthly significant event analysis (SEA) sessions, which all clinical staff are invited to attend, were introduced at an independent Hospice in 2010. SEA allows opportunity for a team to come together and reflect on a clinical event that has had a significant impact for them; in either a positive or negative way. The chair of the clinical quality (now clinical audit) group introduced SEA in recognition that it forms an important part of clinical governance. Guidance was developed outlining how a significant event may be identified, how the sessions would be structured (through use of a specific proforma) and facilitated, ground rules to be followed and including background information on the role of SEA in a clinical setting. Pathways for staff support are also outlined in the guidance. Dates of SEA sessions are issued in advance. The significant event to be discussed and session facilitator are decided at the organisations’ "Implementing Clinical Governance Group (ICGG)". Since it’s introduction, the structure of SEA has been reviewed and adjusted to ensure it is robust from both a governance and learning perspective. This includes ensuring ground rules are set at the beginning of each session and that action points are followed up through ICGG. An aspect we are keen to further develop is the link between SEA learning outcomes and staff education. Examples of topics reflected on at SEA include management of terminal agitation, vulnerable adults, communication, boundaries, expectations, capacity and preferences. SEA is well attended and has received positive verbal, informal feedback with staff voicing they enjoy the sessions and are keen for them to continue. Recently a questionnaire has been developed and sent to all clinical staff to obtain formal feedback to support the development of future SEA sessions.

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