Significant Event Audit

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Significant Event Audit

• A Guide To
• Starting, Sustaining Maintaining

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What is Significant Event Audit?

• Defined as occurring when
• ..individual episodes in which there has been a
  significant occurrence (either beneficial or
  deleterious) are analysed in a systematic and
  detailed way to ascertain what can be learnt
  about the overall quality of care and to indicate
  changes that might lead to future improvements.
  (after Pringle 1995)

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Significant Event AuditWhat it is..

• Inter-professional team activity
• Regular meeting to discuss events (both good and
  not so good)
• Focus on system improvement rather than
  individuals
• Development of a no blame culture

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Introducing Significant Event Audit (1)

• Initial meeting- involve stakeholders
• Identify facilitator
• Meet monthly- substitution not more
• Collect events as they occur
• Record events using forms/books kept in strategic
  places
• If event described in letter from another
  organisation, record details

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Introducing Significant Event Audit (2)

• Collect events a week prior to the meeting
• Create agenda, recognising
• - priority of topics
• - availability of personnel
• - involvement of team members
• - sensitivity of topic
• - flexibility to add hot
  topics

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Introducing Significant Event Audit (3)

• Circulate agenda 48 hours before meeting
• At the meeting
• - run through recording sheet of last
• meeting, in particular action points
• - each topic presented by key person,
• followed by discussion (praise
• before criticism)

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Introducing Significant Event Audit (4)

• Record the key points and actions decided, and by
  whom
• Four outcomes
• CONGRATULATION
• IMMEDIATE ACTION
• NOT RESOLVED (a potential topic
  for quality improvement
• NO ACTION (lifes like that) -
  but I feel better for talking about it

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Benefits of Significant Event Audit

• Key part of Clinical Governance
• Focus on patient outcomes
• Promotes self-esteem and self value
• Identifies communication opportunities
• Comprehensive nature of SEA
• Fulfils team potential
• Personal, professional and service development in
  active way

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Maintaining the process

• A healthy and varied agenda
• Monitor the overall process six monthly
• Rotate the day to benefit part-timers
• Defer some decisions to Practice Meeting
• Summarise actions at end of meeting
• Increase number of congratulations
• Reconsider venue group size

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The Team View

• Looking after each other
• Celebrating aspects of care even in worst
  disasters
• Coming out of hierarchies
• Teams can blow their own trumpet