Significant event auditing

A significant event audit (SEA) is a quality improvement technique. It is a retrospective audit that looks at one case in detail, from beginning to end, to either increase the likelihood of repeating outcomes that went well or decrease the likelihood of repeating outcomes that went badly.

SEAs may result in further development of guidelines, protocols or checklists, and the need for additional clinical audits (process/structure or outcome). They are conducted by bringing your team and relevant case notes together to discuss the event. It is important the event is discussed without any blame, allowing team members to provide honest, constructive feedback on how they contributed to the care process.

SEA stages

An SEA is completed in six stages. The following explains these steps required to perform one.

Identify the significant event

Create a brief description of the event, context and outcome to be discussed in the meeting.

Collect all relevant information

Gather all relevant information, such as files and staff accounts, that contribute to the case.

Meeting and analysis

In a team discussion regarding the event, analyse the event and its causes to suggest where changes can be made. Indicate changes that could aid in achieving the desired outcome. It is important to ensure this meeting provides an environment where all staff members are encouraged to speak freely and honestly.

Decide what changes need to be made

Confirm which changes should be made, and make a prediction on the effect this will have. It may be no change is required or only a need to disseminate the findings. Where changes are made, they could be in the form of checklists, guidelines or protocols. Following the meeting, a final report detailing the key points raised in stages 1 to 4 should be written.

Implement changes

Develop an action plan. What needs to be done by whom, when and how? Ensure the whole practice team is aware of the changes and what role each team member has in implementing them.

Monitor the changes once implemented and set a time to review them. The length of time required for monitoring will be dependent on the event.

Review changes

The team should meet together to review the changes, and discuss what went well and what didn’t. You could also share what you have found with clients and the profession. Further audits may be required to monitor the change.

• The following mock case example (written by members of RCVS Knowledge’s Case Example Working Party: Pam Mosedale, Laura Playforth and Angela Rayner) explains how an SEA works in practice.

A stray kitten was admitted to the branch practice after being found in a garden hypothermic and dehydrated.

Roxana the duty vet gave the kitten a physical exam and ran some basic blood tests, and it appeared in good health. The nursing team named the kitten Logan, and he was placed on IV fluids as he was not initially interested in eating or drinking.

The staff wanted to ensure a fluid pump was used to ensure his fluids were administered accurately. The team already had several pumps in use and were struggling to find the last one in the practice – eventually, Jodie found it in a cupboard in the office, which caused a few jokes about why it had made its way in there.

The rate of fluids was calculated by Roxana and confirmed verbally with Meera the duty nurse, and repeated back in an excellent example of closed loop communication, which the team had been practising.

Date of significant event: 25 April 2019

Date of meeting: 29 April 2019

Meeting lead: Roxana

Team members present: The whole practice team – vets, RVNs, animal care assistants and receptionists

Thirty minutes after the fluids were started, Logan was checked over by Jodie and all seemed to be in order, as it was when he was checked a couple of hours later.

However, a few hours after that, at the end of the day, Meera alerted to Roxana that Logan’s breathing seemed rapid and laboured, and he was blowing bubbles from his nose. As they went to turn off the fluid pump, they realised the door was no longer closed properly and the fluids were freely flowing.

Hearing the commotion, Jodie came over and wondered aloud if this was the pump that had “had a dodgy catch on the door for ages”. Roxana confirmed fluid overload from the symptoms and the amount of fluid that had been used out of the bag.

Fortunately, with symptomatic treatment, Logan was fine and went on to be rehomed successfully via the clinic.

SEA meeting findings

The team felt under pressure to find a fluid pump to ensure the correct fluids were administered to the kitten. It was a busy day with inpatients and all of them were already in use.

Jodie had found the pump in an unusual location, and the team had make a few jokes about the situation instead of pausing to critically analyse why the pump may have been placed there.

Amy, the head nurse, had placed the pump in the cupboard to send off for servicing and repair; however, had not informed the rest of the team that the pump was not working properly.

The kitten was placed in isolation in case he had infectious diseases. Due to his stray status, a hospital sheet had not been filled out and he perhaps was not checked as regularly as the other patients in the hospital.

Why did it happen?

Causal factors were as follows.

System factors

• No good system in place to alert the team of the broken fluid pump.
• Shortage of fluid pumps compared to requirement.
• No protocol on the treatment of stray animals and creation of clinical records for them.
• Standard giving set had been used.

Human factors

• Jodie found the pump in an unusual place.
• The entire team failed to critically analyse why the pump was in this location.
• A busy day, and pressure to find the equipment may have led to this.
• Amy was absent from the clinic that day.

Patient factors

• The kitten was a stray and had been placed in isolation.

Owner factors

• None as there were no owners in this case.

Communication factors

• No communication from the head nurse about the broken pump – she was also absent that day, so couldn’t identify it at the time.
• Some staff members knew of the fault, but didn’t communicate this to others, or know enough to be able to communicate this.

Other

• None

What has been learned?

The team was upset its efforts to improve Logan’s health had caused temporary deterioration; however, they all agreed that without the quick work of Meera and Roxana, it may have had a worse outcome. The team also praised them on their initial closed loop communication regarding the fluid rate and care for Logan.

No current schedule for regular servicing and calibration of fluid pumps was in place. When the other pumps were sent away, the team realised they were very overdue, and one of them was quite inaccurate.

Any future faults were to be promptly communicated to the whole team, and any not suitable for use required clear labelling and to be locked away and/or sent for repair as soon as possible.

The team requested more fluid pumps to be ordered, as they found they required more. They also took this time to remind everyone that if a fluid pump was not available then a burette giving set should be used for smaller patients.

A protocol about the treatment of stray animals was required, and should include an adequate level of monitoring for their condition, and this should be recorded on a hospitalisation sheet and in the clinical notes.

What has been changed?

The following changes were made.

CPD/training required

No official training required; however, discussion of the team’s learnings took place.

New or updated protocols/checklists/guidelines

• New protocol for servicing, calibration and repair of equipment, including what to do with the broken equipment while waiting for it to be sent for repair.
• To continue using closed loop communication to provide a sense check.

Further audit required?

• Audit hospitalisation of stray animals to ensure sheets and records are being filled out, and sufficient monitoring is taking place.
• Servicing and calibration should be checked regularly, and audit compliance with this.

Other

• None

Follow-up date

A follow-up date of 29 June 2019 was decided.

SEA stages

To recap, the following SEA stages were carried out.

1. A patient received a large amount of fluids following the free flow of fluid from a giving set. The error was noticed when the patient had respiratory signs of dyspnoea and fluid leakage from the nares.
2.  An SEA was completed. Details were collected from the team members involved with the patient, team members working on site, hospital sheets and records, and vet directly involved.
3. A meeting was led by the vet involved and the results split into factors that affected the overall results – system, human, patient, owner, communication and other. This helps create a blame-free meeting, looking at all contributions and getting input from all team members.
4. Further protocols needed to be in place for servicing and maintenance of the fluid pumps. This protocol was to include what should be done with the equipment while waiting for it to be sent away for repair. Protocols regarding the treatment of stray animals also needed to be created.
5. The incident was discussed with the rest of the team and it was enough of a near miss to ensure the team were committed to ensuring the changes happened and was maintained. Protocols were drawn up and distributed at a team meeting.
6. Further audits will be required on the new protocols to ensure compliance.