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