Using significant event audit to improve safety in clinical practice
As an NHS patient, you have an expectation that the treatment that you receive will be safe and that any risks that you may be facing will have already been considered and steps taken to ensure that nothing goes wrong... right?
It has been estimated that one in ten patients admitted to hospitals in developed countries will be unintentionally the victim of an error.1 Worryingly, around half of these events could have been avoided if lessons from previous episodes had been acted upon. In the past, attention was generally focused on developments in patient safety within the acute sector, that is until the pioneering work of two GPs following the publication of a Royal College of General Practitioners (RCGP) paper in the mid-1990s. This work appears to have been one of the major catalysts for the global recognition of the patient safety movement in primary care.2
Over recent decades, general practice has taken on more and more services previously only provided in a hospital setting, and the risks have increased as complex practices involving people, skills, technologies and drugs have evolved. Patient safety has and always will be one of the most important considerations, but with the best will in the world, sometimes things can - and do - go wrong.
In a UK study of ten general medical practices in 2003, 940 errors were recorded over a two-week period. The errors were categorised as 42% related to prescriptions, 30% related to communication errors and three per cent of the errors were clinical (with inaccurate note-keeping the main source).3 The most important areas for improving patient safety in general practice have been linked to accuracy of diagnosis, medication - prescribing, dispensing and administration; and communication within practices, between different professions, and between primary and secondary care.4
These categories of risk still feature in the top five risk categories faced by General Practice in 2010 according to data from the one of the leading healthcare indemnity providers, the Medical Protection Society (MPS) (See box 1).5
The National Patient Safety Agency (NPSA) developed a seven step best practice guide aimed specifically for primary care teams to work through in order to safeguard the safety of patients (see box 2)6. It has been recommended that these steps should be followed as part of a continuing process rather than a step-by-step exercise, with the patient experience as the central focus.
SIGNIFICANT EVENT AUDIT
If done well, Significant Event Auditing (SEA) has the capacity to make huge improvements within the patient safety arena.
There are many definitions of what a significant event is, ranging from specific incidents which have caused harm to the patient to broader events that affect the way the health care team performs. It should be remembered that an event can be positive and that we can learn as much from a good outcome as we can from a bad experience. The broad definition used by the pioneers of SAE in General Practice is:
- 'Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice'2
Improving the quality and safety of patients in primary care is a key clinical governance priority. SEAs are now an integral part of the Quality and Outcomes Framework (QOF) and general practices are required to complete a minimum of twelve event reviews over three years.
There are seven key stages of significant event auditing, and they follow the same principles as the seven steps to improving patient safety recommended by the NPSA.7 Following this model can also be used to assist healthcare professionals in demonstrating reflective practice as part of continuing professional development. These stages are:
1. Awareness and prioritisation of a significant event
Staff should be familiar with the process of SEA and should be committed to the routine audit of events as they happen.
2. Information gathering
As much factual detail should be gathered at the time of the event including personal testimonies where appropriate.
3. The facilitated team-based meeting
These meetings should be attended (where possible) by all staff who were involved in the significant event. This can be difficult when events involve multidisciplinary cross boundary colleagues. Meetings should also be structured by a facilitator skilled in ensuring that the process is conducted in a fair, honest and non-threatening manner. Minutes should be taken to ensure that the main learning outcomes are identified and action points agreed.
4. Analysis of the significant event
Four main questions should guide this part of the process, these are:
- What happened?
- Why did it happen?
- What has been learned?
- What action or change is required?
5. Agree, implement and monitor change
Any outcomes requiring action should be designated to the appropriate staff member/s. This enables ownership and allows the relevant individual/s the right to co-ordinate and implement relevant changes required. Progress can be monitored by reflecting on outcomes at future team meetings.
6. Write it up
Keeping a comprehensive and anonymised account of each SEA is essential, as these will be reviewed by external teams to ensure that safety standards have been met.
7. Report, share and review
Accurate reporting of events relating to patient safety and disseminating important findings to relevant clinical governance leaders is essential. Some events may require urgent actions and others more routine measures.
Guidelines for reporting incidents can be requested from your local clinical governance lead or via e-forms at www.nrls.npsa.nhs.uk/report
The National Reporting and Learning service (a branch of the NPSA) undertook a systematic review of SEAs in six PCTs within the East Midlands Strategic Health Authority and found that although the majority met QOF standards, many audits were lacking in basic details and provided limited evidence in relation to reflecting on events and action planning. The lack of multidisciplinary team involvement was also a significant finding.8
CASE STUDY
Mr A had attended the surgery for a routine dressing change following an insertion of seton for an anal fistula at the local hospital. He attended with a sorbsan ribbon dressing pack that the nurse had given him upon discharge from the ward. Having never seen a seton procedure before, and with very little else to go on (as typically happens with such procedures until the paperwork comes through), my nursing colleague completed a sorbsan packing procedure and arranged for daily dressing changes.
After two weeks, we had still been unable to contact the consultant surgeon to elicit an ongoing management plan. It wasn't until the patient was seen by the surgeon for an outpatient review that the story of how Mr A's attendance for daily dressings was relayed. The consultant then responded by letter stating his disbelief that we were unaware that the patient did not require daily dressings but merely a simple gauze dressing to absorb any discharge.
We then emailed all local practices to find out whether this was an in-house lack of knowledge or a more general learning need. The response was unequivocal: the majority of local primary care nurses were neither familiar with the procedure nor the ongoing management. These findings were then reported to the surgeon, who had assumed that the local primary care teams should know about these procedures, which were now standard practice in secondary care.
A clinical team meeting was promptly organised to discuss this significant event. Significant event forms can be downloaded and adapted to allow an in-house structured review of events. They should be used to clarify the issues and what steps need to be taken to minimise the reoccurrence of the incident (See SEA proforma). The detail can be kept to a minimum as long as the key facts and learning outcomes are covered, an action plan agreed and a follow up review organised.
On reflection, we should have invited the ward nurse and the consultant surgeon to the meeting, as they were also members of the healthcare team involved in this event. However, the learning needs we identified have all been largely met following a subsequent, multidisciplinary teaching session conducted by the consultant at our surgery. Local GPs, nurses and allied staff were invited to the talk on current surgical procedures for anal fistula and the ongoing management of these patients. The feedback was very positive and we hope to organise biannual updates for primary care teams locally. We also plan to set up better communication channels between primary and secondary care nursing teams.
CONCLUSION
Significant Event Audit has the potential to make huge improvements in patient safety but only when all parties involved are fully committed to the process.
It does take time and effort by all healthcare teams working together in an honest and open manner to make significant event auditing worthwhile. But if the focus is trained on the patient experience rather than issues such as political and hierarchical agendas, there is no reason why the outcomes for both patient and professional cannot be mutually beneficial.
REFERENCES
1. Carruthers I, Philip P Safety First - A report for patients, clinicians and healthcare managers. London: Department of Health; 2006
2. Pringle, M., Bradley, C.P., Carmichael C.M. et al 1995. Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care.
Occasional Paper No.70. Royal College of General Practitioners. London: RCGP; 1995
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560254/pdf/occpaper00124-0009.pdf
3. Rubin G, George A, Chinn DJ, Richardson C. Errors in general practice: development of an error classification and pilot study of a method for detecting errors. Qual Safety Health Care 2003;12:443-7
4. Ely J, Dawson J, Young P et al. Malpractice claims against family physicians. Are the best doctors sued more? J Family Practitioner 1999;48:23-9
5. Medical Protection Society. Your Practice. Professional Support and Expert Advice for your Practice. 2011; 5(2)
http://www.medicalprotection.org/uk/press-releases/Top-five-risks-in-general-practice-during-2010
6. National Patient Safety Agency. Seven steps to patient safety for primary care. The full reference guide.NHS/ NPSA May 2006
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60044&type=full
7. Bowie P, Pringle M. Significant Event Audit - Guidance for Primary Care Teams
NHS National Patient Safety Agency / National Reporting and Learning Service
www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61501&type=full&servicetype=Attachment
8. National Patient Safety Agency/National Reporting and Learning Service. Analysing Significant Events in General Practice. Executive Study. November 2009
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65673
