Standard operating procedure

Significant Event Analysis Procedure

How [Organisation Name] raises, records, analyses and learns from significant events to improve patient safety and demonstrate good governance.

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  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Principles: a just and learning culture
  • 6. Procedure
  • 7. Learning and sharing
  • 8. Records
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 17 (Good governance)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 20 (Duty of candour)
  • Care Quality Commission (Registration) Regulations 2009 - Regulation 18 (Notification of other incidents)
  • General Medical Council, Good medical practice (2024), and the General Medical Council requirements for appraisal and revalidation
  • Care Quality Commission single assessment framework, in particular the Well-led key question
  • Data Protection Act 2018 and the UK General Data Protection Regulation

Who it applies to

All staff at [Organisation Name], including GP partners, salaried and locum GPs, the registered manager, practice manager, nurses, healthcare assistants, clinical pharmacists, the wider clinical team and all administrative, reception and non-clinical staff.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Anonymised
Having names and other identifying details removed so that no individual patient or member of staff can be recognised.
Appraisal
A regular, structured review of a clinician's work and development, used to support safe practice and professional growth.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Care Quality Commission (Registration) Regulations 2009
The law setting out, among other things, the incidents a provider must formally notify to the Care Quality Commission.
Data Protection Act 2018
The UK law that governs how organisations collect, store and use people's personal information.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
General Medical Council (GMC)
The body that registers doctors in the UK and sets the standards they must meet to practise.
Good medical practice
The General Medical Council's core guidance setting out the standards of professional conduct and care expected of doctors.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting out the fundamental standards that providers of regulated care must meet, enforced by the Care Quality Commission.
Human factors
The way working conditions, workload, environment and the design of systems affect how safely people can carry out their tasks.
Integrated care board
The local statutory body responsible for planning and arranging publicly funded health services in an area.
Just culture
An open and fair workplace culture that learns from mistakes by examining system failures rather than blaming individuals.
Locum
A clinician who works temporarily to cover for a regular member of staff.
Multidisciplinary
Involving staff from different roles and professions working together.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Notifiable safety incident
A patient safety incident serious enough that the law requires the provider to tell the affected person, apologise and follow the duty of candour.
Primary Care Network (PCN)
A group of neighbouring general practices that work together and share resources and learning.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Revalidation
The periodic process by which a doctor demonstrates they remain up to date and fit to practise in order to keep their registration.
Root cause
The underlying system or process reason an event happened, beneath the immediate or obvious cause.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Significant event
Any event, good or bad, that the team considers important to the care of patients or the running of the practice and from which there is something to learn.
Significant Event Analysis (SEA)
A structured team review of a single event to understand what happened, why, and what can be improved.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Standard Operating Procedure (SOP)
A written document setting out the agreed step-by-step way of carrying out a particular task or process.
Triage
Quickly reviewing and prioritising events according to their seriousness and urgency.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Well-led
One of the regulator's five key questions, asking whether a service has good leadership, management and a positive, learning culture.

How it works

  1. Buy securely with Stripe - instant, no VAT, no account needed.
  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

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