Table 1.

Summary of standard SEA framework and report format recommended in NHS Scotland

1. What Happened?
• Collate and record as much factual information as possible about the event including, for example, what happened, when and where, what was the outcome and who was involved.
• Record the thoughts and opinions of those involved, including patients and relatives if appropriate, and attempt to form an accurate impression of what happened
2. Why did it happen?
• Ensure the main reasons why the event occurred are fully established and recorded, e.g. was it a failure in a system or a failure to adhere to protocol?
• Establish the underlying or contributory reasons as to why the event occurred, e.g. why was there a failure in a system or adherence to a protocol.
3. What has been learned?
• Agree and record the main learning issues for the health care team or individual team members.
• Ensure that insight into the event has been established by the team or the individuals concerned
4. What has been changed?
• Agree and implement appropriate action in order to minimize the chance of recurrence, where change is considered to be relevant.
• Monitor the implementation of any change introduced