SIGNIFICANT EVENT AUDIT

1. SIGNIFICANTEVENT AUDIT Jonathan Bayly Chair Gloucestershire PCCAG

2. 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) Gloucestershire PCCAG

3. WHAT IS SIGNIFICANTEVENT AUDIT? Something happens Can we learn anything from this? How do we learn from this? What are the consequences?

4. WHY DO SIGNIFICANT EVENT AUDIT? Clinical governance “Organisations with a memory” Risk management Complaints procedures Personal/practice development plans Appraisal Re-validation requirement?

5. 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 Gloucestershire PCCAG

6. The Philosophy • Change is an emotional process • Harnessing an existing feature of the practice • Structured, rigorous • Not blame allocating but quality oriented Gloucestershire PCCAG

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8. Examples of Significant Events • Clinical • New cancers • Pregnancies with contraception • Sudden deaths • Chronic diseases (e.g. epilepsy, MS) • Traumas, suicides Gloucestershire PCCAG

9. Examples of Significant Events Clinical • Myocardial infarctions • Strokes • Acute infections, e.g. meningitis • Drug reactions • Terminal care Gloucestershire PCCAG

10. Examples of Significant Events • Administrative • Patient complaints • Aggressive patients • Dispensing/prescription errors • Home visits not done • Breaches of confidentiality Gloucestershire PCCAG

11. Examples of Significant Events • Administrative • Rota problems • Staff upsets • Communication failures (e.g. referrals) • Appointment difficulties • Medico-legal issues Gloucestershire PCCAG

12. 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 Gloucestershire PCCAG

13. Things to include in a report A simple statement is sufficient … Or a more detailed log … Gloucestershire PCCAG

14. 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 • Reporter’s identity (optional) Gloucestershire PCCAG

15. 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) Gloucestershire PCCAG

16. Outcomes • Congratulations and celebration • Conventional audit or clarification • Immediate action • Guidelines • Education • Research • No action Gloucestershire PCCAG

17. What makes it work? • Overcome shyness, nervousness initially • Reassure staff not involved • Confidentiality of facilitator • Role of Practice Manager • Structure of meeting Gloucestershire PCCAG

18. What makes it work? • Humour • Sensitive issues handled well • Fresh items • Maintaining impetus/time • Trust and communication • Firm facilitation Gloucestershire PCCAG

19. 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? Gloucestershire PCCAG

20. 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 Gloucestershire PCCAG

21. Weaknesses • May be superficial • May be threatening • Emotionally demanding • May expose issues that are difficult to resolve • Requires a coherent team Gloucestershire PCCAG

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24. “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 Gloucestershire PCCAG

25. 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 Gloucestershire PCCAG

26. 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 Gloucestershire PCCAG

27. National Patient Safety Agency Prof Rory Shaw, Chair NPSA Gloucestershire PCCAG

28. NPSA definition “Any event or circumstance that could have lead to un-intended or unexpected harm, loss or damage” Gloucestershire PCCAG

29. 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 Gloucestershire PCCAG

30. Where to go for further help! Gloucestershire PCCAG

31. 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 Gloucestershire PCCAG

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33. Risk Management

34. 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. Gloucestershire PCCAG

35. 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 Gloucestershire PCCAG

36. Relationship to critical event audit Gloucestershire PCCAG

37. 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 Gloucestershire PCCAG

38. Examples

39. 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 Gloucestershire PCCAG

40. Non-clinical • Maintenance of equipment • Maintenance of buildings • Waste management • Infection control • Fire safety • Employers liability • Message handling • Staff turn-over • Security of information Gloucestershire PCCAG

41. 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 Gloucestershire PCCAG

42. 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 Gloucestershire PCCAG