PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Significant Event Audit

Definition: Significant event audit (SEA) has been defined as occurring when "individual cases in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) 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" ¹

Also known by by other names

• Critical event audit
• Critical incident analysis
• Structured case analysis
• Facilitated case discussion ²

All of the above are based on a careful and structured dissection of a single case, and ask the crucial question "How could things have been different, what can we learn from what happened, and what needs to change?"³

Aims The aim of facilitated discussions is to identify events in individual cases that have been critical (beneficial or detrimental to the outcome), with a view to improving the quality of care without attributing individual blame or self-criticism. The critical events may be clinical, administrative, or organisational²

History There have been a number of government documents concerning quality in the NHS in an attempt to reduce the risks to patients^4,5,6. These identified the significant opportunities that exist to reduce unintended harm to patients arising during NHS care. The National Patient Safety Agency (NPSA) was set up (2001) with the aim of improving the safety and quality of care through reporting, analysing and learning from adverse incidents and 'near misses' involving NHS patients.⁷

The technique of SEA is based on work on the critical incident technique performed during World War II by an aviation psychologist called Flanagan ⁸. This laid the foundations for its widespread use in business, health care, organisational psychology and education.

The focus on the team in SEA is one of the main differences from the critical incident technique as developed by Flanagan, which looked at the practice of individuals.²

Process
Participants are asked to recall personal situations that they feel represent either effective or ineffective practice, these are then reviewed by the group. From such review of individual cases arise general standards to improve the quality of care^2,3.

For a critical incident technique to be a useful learning experience or trigger for change, three pieces of information must be included ⁹

• A description of the situation that led to the incident;
• The actions or behaviours of those involved in the incident;
• The results or outcomes of the behavioural actions.

The participants describe what first occurred, the subsequent events, and why they perceived the incident to be an example of effective or ineffective practice. ²

Considerations:^2,3,10

• Select time, duration, setting and equipment. A comfortable, quiet room is essential. Holding the discussions during the day makes it easier for all staff to attend but difficult to avoid routine interruptions. The length of a discussion will vary, but between 20 and 45 minutes will generally be needed for each case. Cases generating emotive topics may need up to an hour.
• Forming the group. The primary health care team, in consultation with the facilitator(s), should initially decide who will take part in the discussions, they should then be formally invited. ^2,3 Decide on the size of the group: Generally large groups function less well than small groups;
• Decide on a facilitator: Important to get right. See references below for a fuller discussion.
• Rules and guidelines. Participants need a clear set of rules, particularly at the outset.
• Ownership and commitment. Commitment can only be assumed if the participants' need for safety has been addressed. The evolution of Practice Professional Development Plans (PPDPs) ¹⁰ can contribute to formal acknowledgement of SEA for all participants, which will help build corporate ownership.
• Topic choice, the needs of all team members must be borne in mind when the list of topics is drawn up. They should be vetted however, as not all may be appropriate for group discussion.
• Documentation: Relevant discussion points and any decisions made should be documented.
• Management of the process, needs to be active i.e. arrange follow up meeting, important to ‘close audit loop’, some members may need debriefing afterwards.

Benefits ^1,3 Studies have shown that participants generally appreciate (for full details see references):

• The opportunity, indeed permission that SEA gives to come forward with problems and difficulties as well as suggestions and advice.
• The chance for team building: the creation of trust, mutual understanding and appreciation of other members' contributions.
• The effect on the work environment – enhanced and a better quality service could be offered, which itself further improved morale.
• The multidisciplinary format, offering opportunities to learn about others' experiences and opinions, both in clinical care and administrative practice to work together to problem solve and to resolve conflict, often without personalization.
• The SEA’s effect on individual development both within and alongside the team, and prompt to educational activity.
• That Guidelines for managing a variety of different situations being discussed can be a way to initiate changes in policies and practice.
• That people could be reassured they were ‘on track’ and an agreed direction of travel established, with the opportunity for everyone present to contribute.

Difficulties^2,3,10 Need to be anticipated to overcome.

• Time restrictions – if too short participants can feel that quick, easy or superficial solutions might be adopted. Finding the time for the meeting can be difficult, especially when part-time staff have to make special arrangements to attend.
• Members also recognized that it was sometimes difficult to be sufficiently honest. There was a Pandora's box fear: that lifting the lid might release uncontainable pressures with unexpected consequences. The danger is that SEA is confined to safe ?trivial’ areas and loses effectiveness.
• Emotionally demanding.
• Problems with structuring the meetings, some issues may be difficult to resolve and there may be a need for extra training of staff.
• Group dynamics: some group members may feel vulnerable in speaking out, especially if their contribution might be seen as critical of those perceived to be of higher status.
• SEA often a new and often uncomfortable experience for most of the team who may find the critical process generally disconcerting and could be embarrassed by revelations of other members' shortcomings.
• Debriefing time: often other tasks immediately afterwards without adequate opportunity to talk things over.
• Non-doctors were concerned that GPs' topics might dominate the agenda.
• Externally employed staff could be stressed, with loyalties to the GPs and their own management structure sometimes in conflict, which could interfere with SEA
• Motivation. The selection of topics affects motivation. Because the leaders were more inclined to choose events that involved them, clinical GP topics could dominate SEA, particularly at first. This could alienate non-clinical staff. GPs' motivation is increased by PGEA approval for attending (with no similar reward for other groups) and a social benefit.
• Confidentiality and fear of medical litigation.
• Inability to recognise poor standards of care and so no changes made.

References

1. Pringle M, Bradley CP, Carmichael CM, et al; Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care.;Occas Pap R Coll Gen Pract 1995 Mar;(70):i-viii, 1-71.
2. Robinson LA, Stacy R, Spencer JA, et al; Use facilitated case discussions for significant event auditing.;BMJ 1995 Jul 29;311(7000):315-8.[abstract]
3. Greenhalgh T. Significant Event Audit [Doctors.net.uk CME module]
4. A Commitment to Quality, A Quest for Excellence, published on 27 June 2001, Dept of Health
5. An Organisation with a Memory Dept of Health
6. Building a Safer NHS for Patients Dept of Health
7. Patient safety agency
8. Flanaghan J. The critical incident technique. Psychological Bulletin 1954; 51: 327-358.
9. Anderson L, Wilson S. Critical incident technique. In Whetzel DL and Wheaton GR. Applied Measurement Methods in Industrial Psychology. Davies-Black Publishing, Palo Alto, California, page 89-112, 1997
10. Westcott R, Sweeney G, Stead J; Significant event audit in practice: a preliminary study.;Fam Pract 2000 Apr;17(2):173-9.[abstract]

Acknowledgements EMIS is grateful to Doctors.net.uk for facilitating draft authoring of this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2003.

Last issued 05 Jul 2006