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How to undertake significant event audits

Auditing critical events is crucial to avoid claims and improve patient safety, says Dr Pallavi Bradshaw.

A significant event may cover issues such as misdiagnosis (Photograph: SPL)
A significant event may cover issues such as misdiagnosis (Photograph: SPL)

Significant event audits (SEAs) should be an integral part of modern clinical practice, but the experience of the Medical Protection Society (MPS) is that many practices do not have an effective system for SEAs.

Often practices see it as an unnecessary, time-consuming process, while some fear it could be used as a precursor to disciplinary action.

However, it is important to see SEAs as a governance tool that aids professional development and is essential for revalidation.

GPs need to establish a fair and transparent policy that is part of routine practice.

What is a significant event?
A significant event is any event thought to be of significance to patients' care or practice conduct. SEAs should include positive and negative incidents.

The event may cover both clinical and administrative issues such as misdiagnosis, poor outcome, near miss systems failure, human error and unexpectedly good outcome.

When should you use SEAs?
Practices should consider conducting SEAs when an incident has occurred and the reason why needs to be established.

The process allows for strengths and weaknesses in systems or patients' care to be identified and changes implemented to improve quality, prevent repetition of poor practice and reinforce areas of good practice.

While vital to improving patient care, there may also be an implied contractual obligation. GMS and PMS contract regulations state the contractor 'shall have an effective system of clinical governance'.

It is therefore likely that such systems would be expected to include carrying out regular and routine SEAs.

The MPS advises that SEAs should be performed as part of routine complaints handling. This not only allows matters to be openly and objectively investigated, it also minimises the risk of criticism of not engaging in reflective practice.

If something adverse has occurred, complainants want answers as to what happened and why, including reassurance that it will not be repeated.

The SEA should give the answers and allow the team to minimise the risk of recurrence.

During inquests, coroners often ask if an SEA has been carried out and what lessons have been learnt.

The GMC guidance Good Medical Practice also states that doctors must recognise and report adverse incidents and provide the patient with a full explanation.

Who should be involved?
All practice staff should be encouraged to be involved and they must be reassured that an SEA is not designed to apportion blame.

The team can feel empowered by encouragement to report and to participate in structured SEA meetings.

This allows for organisational improvement and can facilitate cascading information required to make changes.

Celebrating success will also help improve staff morale and encourage learning from each other's successes.

THE SEVEN STAGES OF SEA
  1. Awareness and prioritisation of a significant event.

  2. Information gathering.

  3. Facilitated team-based meeting.

  4. Analysis of the significant event.

  5. Agree, implement and monitor change.

  6. Write up report.

  7. Share and review.

Source: National Patient Safety Agency

How to undertake an SEA
The SEA should answer these key questions: what happened and why? What should have happened? Why did this not happen? What can we learn and what needs to change?

To complete the audit loop the process should be reviewed to ensure that any changes are being adhered to and are effective.

It is imperative to ensure that information recorded in the SEA report is full and accurate. The simpler the report's format - see the example above - the easier it is to identify key facts and learning points.

The report should be a standalone document that is self-explanatory and demonstrates that a thorough analysis of the background, facts and learning points has occurred.

Storing SEA reports
SEA reports are disclosable under the Data Protection Act 1998 so it makes sense to save them in the patient's notes. The practice may also wish to keep a copy in a central file for ongoing audit. Alternatively, if relevant, put it in the complaint file.

GPs should also collate SEA reports for appraisal folders as they are needed for revalidation.

Sharing SEAs
Always write the report with the expectation that the patient will see it. The report should be shared with any third party (after anonymising it) so they can learn from the incident or assist in facilitating understanding, such as the primary healthcare team, primary care organisation or the National Patient Safety Agency's National Reporting and Learning System (www.nrls.npsa.nhs.uk).

Practices should not fear the SEA's conclusions. An SEA does not mean they will be blamed for incidents or exposed to a claim.

Not performing adequate SEAs can lead to more criticism and you could be seen to be in breach of your contractual and professional obligations.

Practices should embrace SEAs as an essential tool to improve patient care and services.

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • With your practice team, review any SEAs recently undertaken to ensure learning points have been incorporated into daily practice.
  • Undertake a real (or mock) SEA using the example form above.
  • Update your practice's SEA form to ensure it is fit for purpose and will enable you to collect all pertinent details of an incident.

Save this article and add notes with your free online CPD organiser at gponline.com/cpd



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