Significant Event Audit

A Guide To

Starting, Sustaining & Maintaining

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)

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

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

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’

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)

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 (‘life’s like that’) - ‘but I feel better for talking about it’

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

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

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