SIGNIFICANT EVENT AUDIT

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SIGNIFICANTEVENT AUDIT

• Jonathan Bayly
• Chair Gloucestershire PCCAG

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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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WHAT IS SIGNIFICANTEVENT AUDIT?

• Something happens
• Can we learn anything from this?
• How do we learn from this?
• What are the consequences?

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WHY DO SIGNIFICANT EVENT AUDIT?

• Clinical governance
• Organisations with a memory
• Risk management
• Complaints procedures
• Personal/practice development plans
• Appraisal
• Re-validation requirement?

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Historical Perspective

• Secondary Care
• Cases Post-mortem to CEPOD
• Cohort Audit - recent
• Primary Care
• Cohorts Nightingale to Donabedian
• Cases Balint, random case analysis
• and Significant Event Auditing

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The Philosophy

• Change is an emotional process
• Harnessing an existing feature of the practice
• Structured, rigorous
• Not blame allocating but quality oriented

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Examples of Significant Events

• Clinical
• New cancers
• Pregnancies with contraception
• Sudden deaths
• Chronic diseases (e.g. epilepsy, MS)
• Traumas, suicides

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Examples of Significant Events

• Clinical
• Myocardial infarctions
• Strokes
• Acute infections, e.g. meningitis
• Drug reactions
• Terminal care

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Examples of Significant Events

• Administrative
• Patient complaints
• Aggressive patients
• Dispensing/prescription errors
• Home visits not done
• Breaches of confidentiality

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Examples of Significant Events

• Administrative
• Rota problems
• Staff upsets
• Communication failures (e.g. referrals)
• Appointment difficulties
• Medico-legal issues

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How to get the ball rolling

• Initial meeting to decide on
• Method of reporting - log book or report form
• Chair facilitator
• Constituency
• Ground rules
• Structure of significant event meetings

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Things to include in a report

• A simple statement is sufficient
• Or a more detailed log

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A structured report

• Identity of patient/staff member if appropriate
• Date/time if appropriate
• Actual or potential event?
• Brief summary of event
• Health and safety issue?
• Action taken already
• Were patient/carers informed?
• Suggestions to prevent recurrence
• Reporters identity (optional)

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Process of the Meeting

• Check action on decisions from previous meeting
• Invitation to each person or group to present a
  case
• General discussion
• Decisions (if any)

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Outcomes

• Congratulations and celebration
• Conventional audit or clarification
• Immediate action
• Guidelines
• Education
• Research
• No action

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What makes it work?

• Overcome shyness, nervousness initially
• Reassure staff not involved
• Confidentiality of facilitator
• Role of Practice Manager
• Structure of meeting

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What makes it work?

• Humour
• Sensitive issues handled well
• Fresh items
• Maintaining impetus/time
• Trust and communication
• Firm facilitation

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Main points to be considered

• Enjoyable
• Challenging
• Complements other quality activity
• Leads to real challenge
• Involves more members of the team
• More time effective than conventional audit?

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Strengths

• Outcomes focused
• High emotional appeal
• Deals with real problems
• Breadth of issues
• Less preparation
• Less reliant on records
• Immediate feedback
• Team building
• Raises interface and team issues

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Weaknesses

• May be superficial
• May be threatening
• Emotionally demanding
• May expose issues that are difficult to resolve
• Requires a coherent team

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• It is a mark of the educated man and a proof of
  his culture that in all matters he looks for only
  as much detail as the nature of the problem
  permits or its solution requires.
• Aristotle

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Organisations with a memory

• Unified mechanism for reporting and analysis
• Near miss concept
• A more open culture to discuss service failures
• Mechanism for ensuring change happens as a result
  of lessons learned
• Systems approach in preventing, analysing and
  learning from errors

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Organisations with a memory

• Mandatory reporting scheme for adverse health
  care events and specified near misses
• Encourage a reporting and questioning culture
• Single overall system for analysis and
  disseminating lessons
• Make better use of existing sources of
  information on AEs
• Improve the quality and relevance of AE inquiries
• Undertake a programme of basic research
• Use new NHS information systems to help staff
  access learning from AE
• Ensure lessons are implemented quickly and
  consistently
• Focus on frequent offenders

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Why NPSA was born

• A number of widely publicised high profile cases
• 850,000 adverse incidents per year 1/3 leading
  to disability or death1
• 50 avoidable according to US studies
• 2 billion/year in additional in-patient stays
• 400 million in compensation
• 1 Vincent C, BMA conference, March 2000

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National Patient Safety Agency
Prof Rory Shaw, Chair NPSA
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NPSA definition

• Any event or circumstance that could have lead
  to un-intended or unexpected harm, loss or damage

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Possible reportable incidents

• Unexpected death while under direct care
• Death on premises
• Suicide/homicide by patient under treatment for
  mental disorder
• Potentially lethal or serious health care
  associated infection
• Proven rape
• Wrong patient/body part
• Retained devices
• Haemolytic transfusion reaction
• Child abduction or incorrect discharge
• Incorrect radiation exposure

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Where to go for further help!
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Resources

• http//www.npsa.org.uk/publications
• An Organisation with a Memory Report from an
  expert group on learning from adverse events in
  the NHS DOH June 2000
• MDU practice based seminars on Risk Management,
  SEA and AIR
• Adverse Incident Reporting available from MDU
  this summer

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Risk Management
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What is risk?

• Risk is the probability that a situation will
  produce harm under specific conditions - the
  probability that something you do not want to
  happen will happen.
• It is measured in terms of likelihood and
  consequences.

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Risk Management

• Focus on the system rather than the individual
  incident
• It is anticipatory not reactive in emphasis
• Significant event audit therefore supports risk
  management by monitoring it

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Relationship to critical event audit
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Benefits

• better outcomes and patient satisfaction
  (improved quality of service)
• ability to learn from mistakes
• reduced costs of litigation and compensation
• better public image
• better allocation of resources
• more informed decision-making
• greater compliance with legislation
• greater transparency and accessibility to
  external review

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Examples
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Clinical

• Failure to adequately examine a patient
• Failure to fully document or send samples to the
  lab
• Prescribing errors
• Dispensing errors
• Inadequate records
• Inexperienced clinical staff
• Inadequate/unavailable medical records
• Failure to provide informed consent

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Non-clinical

• Maintenance of equipment
• Maintenance of buildings
• Waste management
• Infection control
• Fire safety
• Employers liability
• Message handling
• Staff turn-over
• Security of information

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Key requirements

• Leadership and commitment of an identified
  individual
• Policy and strategy
• Planning and organisation
• Resourcing
• Process - incident reporting and investigation or
  complaints handling
• Measurement evaluation and improvement
• Audit

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The risk management mentality

• Will look for near misses
• Will look for danger ahead
• Will put patient safety first
• Will reflect on clinical and non-clinical care
• Will communicate
• Will accept change
• Will be responsive