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Significant Event Audit

Introduction and Background

Significant event audit (SEA) is a risk management technique that is becoming increasingly popular in NHS and wider healthcare circles. The origins of SEA are not entirely clear, but many suggest that it has evolved from the Critical Incident Technique adopted by JC Flanagan and used by the United States Air Force in the 1940s and 1950s. Arguably the key moment in the development of SEA in the NHS was Professor Mike Pringle’s ‘Occasional Paper on Significant Event Auditing’ published by the Royal College of General Practitioners in 1995. From this point, SEA gathered momentum in general practice and was subsequently included in the Quality and Outcomes Framework as part of the GP Contract from 2003 onwards.

With the publication of important documents such as ‘Organisation with a memory’ (2000) and ‘Building a safer NHS for patients’ (2001) plus the establishment of the National Patient Safety Agency (NPSA) in 2001 focus on various risk management techniques gathered pace with SEA an undoubted beneficiary of this. By 2008 the NPSA were actively endorsing SEA and marked this via the publication of their comprehensive resource ‘Significant Event Audit: Guidance for Primary Care Teams’.

Although SEA undoubtedly took root in general practice during the first decade of the 21st century, the technique is now being adopted by a wide range of healthcare teams and professionals. The introduction of revalidation for doctors in December 2012 has also raised the profile of SEA as all doctors must now review and reflect on significant events that they have been involved in and document this as part of their supporting information for revalidation.

Why SEA is important today?

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Quite simply patient care in all sectors of healthcare is increasingly under the microscope. High profile cases such as the Bristol Royal Infirmary Inquiry (2001) and the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) have increasingly focused media and public attention on appropriate care and patient safety.

Research into patient safety has identified that avoidable mistakes continue to happen and a good example of this is the fact that 25 patients taking methotrexate died between 1990 and 2000. For information, methotrexate is a cancer drug that patients should take weekly but many were prescribed the drug on a daily basis. In addition, year-on-year the NHS is seeing the number of negligence claims and associated compensation payouts increasing. The National Reporting and Learning System tracks patient safety incidents in the NHS and currently receives approximately 100,000 reports per month.

Many recent reports have identified that organisations, teams and individuals must find ways of sharing learning from patient safety incidents and adopt risk management techniques that help prevent avoidable errors and mistakes from being repeated. In 2013 Donald Berwick (pictured) published his report ‘Improving the safety of patients in England’ and this included a series of recommendations. It is particularly relevant in relation to SEA that one key recommendation from Berwick was ‘the mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives’.

What is significant event audit?

There are a number of accepted definitions for SEA. In 1995 Professor Mike Pringle defined SEA as: ‘A process in which individual episodes (when 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’.

For the purpose of doctor’s revalidation requirements, the General Medical Council have agreed the following definition: ‘A significant event (also known as an untoward, critical or patient safety incident) is any unintended event, which could or did lead to harm of one of more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented’.

In layman’s terms, significant event audit is all about reviewing, reflecting and learning. Unlike clinical audit, SEA focuses on singular events and is not standards-based. SEA and Root Cause Analysis (RCA) are also often confused and the main difference is that SEA is a practical team-based approach to risk management whereas RCA is a much more in-depth investigative approach often carried out by external bodies.

The SEA process

The NPSA guide from 2008 is arguably the most comprehensive current SEA resource and this advocates a simple seven-stage approach to carrying out significant event audit in practice.

The seven stages are as follows:

  • 1. Awareness and prioritisation of a significant event
  • 2. Information gathering
  • 3. The facilitated team-based meeting
  • 4. Analysis of the significant event
  • 5. Agree, implement and monitor change
  • 6. Write it up
  • 7. Report, share and review

Useful resources

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If you would like to find out more about best practice in significant event audit, you may wish to consider attending one of the accredited courses offered by the Clinical Audit Support Centre. Our SEA Masterclass is a popular course that is periodically held in Leicester but can also be delivered in-house. To access the course flyer, click here.

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This comprehensive 34-page guide was published by the NPSA and is authored by Paul Bowie and Professor Mike Pringle. The guide features a brief history of SEA, a full guide to conducting effective SEA and four useful case studies. The report is also available as a condensed two-page summary document. Click here, for access to the full and condensed guides.

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This insightful book written by Dr. Jonathan Stead and Dr. Grace Sweeney provides the background, evidence and context of significant event audit. This book is authored by two GPs and is available via Kingsham Press. There is a foreword by Professor Mike Pringle and its eleven chapters provide a practical and very readable guide to setting up effective SEA. Order the book by clicking here.

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Although this excellent document does not focus specifically on SEA, it includes a collection of personal testimonies from senior staff who reflect on errors and mistakes that they have made during their medical career. An invaluable read for all and available to download by clicking here.

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