Significant Event Analysis

Reflection on actual patient care is a powerful learning tool. Any death and any un-planned admission in the last year of life is a significant event. Ideally the team should reflect on their part in the event and use their reflections to improve care for the future. This is not about pointing the finger, it is about identifying ways to improve in a non-judgemental fashion. GSF recommends using the 'Traffic Lights System' to analyse events and then making an action plan to improve care.