User Story: Practice based learning using significant event analysis

In what situation? Learning trigger?

Liz is a GP and presents a significant event at the regular practice learning meeting. The significant event is a patient (an 83 year old lady) who suffers a broken hip following a fall at home. The patient was taking metformin for her diabetes and her daughter says that for the few days before the fall, the patient had been feeling faint at the end of the day and she thinks it was due to a high dose of the metformin. The patient or daughter did not contact the GP or surgery until after the fall. Two weeks before this event, the District Nurse had routinely visited the patient for the six monthly diabetes check and her measured blood sugar and HbA1C were within the normal range at this time. The District Nurse will have added this information to the patient’s record in SystmOne but will not have discussed it with Liz (the GP) as the results were normal. Two GPs could not attend the meeting due to holidays and the GP registrar was also unable to attend as she was at the weekly training event.

What happens? (Sequence of the main actions performed), With which tools and physical objects?, Which actors are involved?

  1. Liz asks the practice meeting (4 GPs – one with a special interest in diabetes, three district nurses – one with a special interest in diabetes and 3 practice nurses) if the fall could have been related to the metformin and if it could have been prevented.
  2. There is a face to face discussion between the practice members and they all agree that it was unlikely that the metformin was the cause of the fall but recommend warning elderly diabetic patients on medication to call the practice if they are feeling unwell.
  3. The main participants in the discussion were the GP and practice nurse with special interests in diabetes.
  4. After the meeting, Liz writes up the significant event analysis on a Word document and uploads it to the practice Share Point site on the practice intranet (hosted on the practice’s own server), along with a brief note in the practice minutes.
  5. The practice minutes are sent as an email attachment using NHS Webmail to all the members of the practice team, including those not attending the meeting. These minutes include the advice to warn elderly diabetic patients on medication to contact the practice if they feel unwell.
  6. Liz also stores the significant event analysis (Word document) on her home computer , with the intention that it will be uploaded to the interactive pdf document (as evidence of her continuing professional development) required for her appraisal and revalidation at the end of the year.
  7. The next day, Ian (one of the two GPs who could not attend the practice meeting in which the significant event was discussed ) reads the email report of the event on the practice computer .
  8. Two weeks later, Ian sees a 78 year old patient in the surgery with a chest infection. He sees from the practice computer screen on Systm One that the patient is taking metformin. The patient says that he has occasional lightheaded episodes when standing up. Ian arranges for the patient to have a blood test performed by the practice phlebotomist (an assistant who only takes bloods) for a blood sugar check to see if it is low but does not give a reason for taking the blood test on the clinical entry.
  9. At the beginning of the following week, Ian is away on holiday when the blood sugar result arrives back. The result is passed to Bill (the other GP who could not attend the practice meeting in which the significant event was discussed, but Bill has not read the subsequent email sent to the practice team). The result is normal but Bill is not sure why the blood test had been performed. Because the last entry by Ian stated that the patient had occasional episodes of lightheadness when standing up he arranges with the receptionist to phone the patient and to arrange an appointment at the end of the week
  10. Bill sees the patient at the end of the week and fully examines the patient and can find no reason for the occasional dizziness. He tells the patient to contact the practice again if these symptoms worsen. Bill wonders why Ian had requested the blood test
  11. Bill emails Ian by using NHS Webmail on the practice computer to ask why he had requested the blood test
  12. Ian returns the email to Bill by NHS Webmail using the practice computer and in the email he states what was discussed at the practice meeting and that full details are on the practice sharepoint site
  13. Bill reads the reply NHS email from Ian on the practice computer. Bill is happy with Ian’s explanation and the advice that he (Bill) has subsequently given to the patient and so Bill does not read the actual report on the sharepoint site.

The final result

  1. Liz was able to learn by sharing her problem (learning need) with the practice team at a regular face to face meeting.
  2. The problem is answered by local expert opinion and entirely within the practice
  3. The learning from the practice meeting is circulated to practice team members not present to support any learning needs that they may have identified. However, the significant event summary is stored on the intranet, being identified only by the date of the practice meeting and so this is not easy for anyone to find when they do have a related learning need or want to check the details of what was discussed and agreed.
  4. Liz has effectively re-used the report she wrote as evidence of her continuing professional development. She may have been less likely to do this if she had not already agreed to write the summary to share it with the rest of the practice – i.e. she is doing this because it is not creating much extra work and the record of the learning (the report) is already electronic.
  5. The other staff (involved in the discussion at the meeting) have learned as they have jointly analysed the problem, developed a better understanding of what happened and developed new guidelines to help prevent this re-occurring.
  6. This episode affects the practice of those staff who were at the meeting since next time they see an elderly patient with on medication to remind them to contact the practice if they do start to feel unwell. They tailor this advice so that they are more likely to emphasise it to patients who are infrequent users of the practice and less likely to emphasise it to patients who are in very regular contact with the practice anyhow.
  7. These staff could use the meeting minutes or the significant event analysis as evidence that they were involved in learning, but in general they do not do this perhaps because they see this more as Liz’s learning due to her original ownership of the problem and her writing up the resulting analysis.
  8. Liz’s appraisal is not shared, except confidentially with the appraiser
  9. Ian does learn from this episode even though he was not at the meeting as he read the minutes and the report and was able to put them into practice a few weeks later. Ian always skim reads the minutes of meetings that he was not able to attend just in case he spots something that seems particularly relevant or interesting. He finds picking out key information from written text quick and easy, uses Sharepoint very regularly and so does not consider this reading of minutes and reports to be very onerous and believes he benefits from it.
  10. Bill would not really consider himself to have learned from this episode. He did not have time to read the minutes or report and he only found out about the new advice from Ian as part his and Ian’s joint care of this particular patient. However, Bill is now informed about the new advice (having had the email response from Ian) and is happy to accept this without going into the details of reading the report. So it will now affect his future practice. In general Bill does not enjoy wading through lengthy minutes and reports, much of the detail of which seems not to be relevant at the time to him and he therefore rarely reads minutes or reports if was not at the meeting. He tends not to use IT systems such as Sharepoint regularly and therefore finds that when he does have to use them it takes him a long time and is frustrating. He prefers to get advice/guidance from someone he respects and trusts when it is needed and believes that this approach works well for him.



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