Many dentists view clinical audit as a necessary evil – “it’s done because we have to”. Indeed, the General Dental Service (GDS) terms of service require us to complete 15 hours of audit in every three-year cycle, though recent figures suggest that less than 50 per cent of dentists have done so.
Last year an NHS document distributed to all practices stated: “where a dentist did not undertake the required 15 hours of clinical audit activities under the 1996 regulations he/she will require to complete five hours of clinical audit activities before 31 July 2011’’. No doubt many of us will be looking for 5 hours of clinical audit very soon.
My article in the last issue of Summons argued that a wellstructured, meaningful clinical audit can greatly improve a practice but if you still find the prospect daunting then significant event analysis (SEA) may be your answer! Not only will GDS accept SEAs for the full 15-hour clinical audit requirement, it’s also a process that you can make an almost instant start on and one that will be directly relevant to your practice.
What is an SEA?
A significant event can be described as “any event thought by anyone in the healthcare team to be significant in the care of patients or the conduct of the practice or organisation” (Pringle et al). Significant event analysis has been around for years in the military and aviation Industry. Not only are accidents fully investigated but any near misses are also analysed for useful information to contribute to protocols towards improving passenger safety.
To this day there are approximately 30,000 near misses reported annually in the aviation industry. Similar figures also exist in medicine, and Science Daily reported in 2008 that medical errors cost the US $8.8 billion and resulted in 238,337 potentially preventable deaths between 2004 to 2006. Lessons can be learned from these accidents, errors and near misses.
The Oxford English Dictionary defines significant as “extensive or important enough to merit attention.” This covers just about anything as long as one of your team members considers it important enough to merit further study. Analysis is simply a systematic process to ascertain what can be learned about the event and what changes might be made to foster improvement.
We can basically analyse almost any kind of significant event. Let’s break them into four main groups:
1. A near miss (incident) – e.g. forgetting not to wear latex gloves in treating an allergic patient but no harm done as this is realised in time.
2. An adverse event (accident) – e.g. forgetting not to wear latex gloves and the patient has an allergic reaction.
3. An error – e.g. wrong patient records or records not written up correctly to indicate latex allergy, however no harm done.
4. Good practice – e.g. notes clearly indicate latex risk and robust protocol in place to ensure the patient is not exposed to latex; correct procedure carried out.
I'm sure you can already think of more examples from your day-to-day practice of all four of these. Such events can involve almost anything from lab work to staff training, from data protection to patient safety. Should you have lots of potential SEAs already, it is suggested that they be prioritised on the basis of consequences (actual or potential) for the quality and safety of patient care.
Why analyse significant events?
In the case of a good event, that’s easy – we would all like to bottle the formula that makes our day run like clockwork and repeat it on a regular basis. When something goes wrong (or almost does) we want to make sure it doesn’t happen again. Without proper systematic analysis, it’s too easy for us to jump to conclusions – to blame a nurse or that lab!
But it may be that the problem lies much closer to home. Perhaps it is a training gap or even poor communication. A structure reduces speculation and conjecture and focuses more on the factual evidence. Any resulting change in practice is likely to be more positive than just “we must try harder”.
Analysis helps us view incidents as important learning and quality improvement opportunities. It allows us to gain insight into what happened and take appropriate action. SEA is a highly flexible, non-threatening and team-based method of identifying training, managing risk and enhancing patient safety.
Do it right
There are seven steps to a good SEA:
Step 1 – Identify your significant event.
Step 2 – Collect and collate as much information as possible relating to the event for all people involved.
Step 3 – Convene a meeting with a non-threatening, no blame, egalitarian approach, focusing on the educational outcome.
Step 4 – Undertake a structured analysis (see below).
Step 5 – Monitor the progress of all actions/changes agreed upon as a result of the analysis.
Step 6 – Write up the SEA.
Step 7 – Seek educational feedback – peer review. A good SEA will be relevant and can be a lifelong learning tool. The framework for the structural analysis is outlined in the following four questions:
1. What happened? Describe what actually happened in detail and chronological order. Consider, for instance, how it happened, where it happened, who was involved and what the impact or potential impact was on the patient, the team, organisation and/or others.
2. Why did it happen? Describe the main and underlying reasons – both positive and negative – that contributed to why the event happened. Consider, for instance, the professionalism of the team, the lack of a system or a failing in a system, lack of knowledge or the complexity and uncertainty associated with the event.
3. What has been learned? Demonstrate that reflection and learning have taken place on an individual or team basis and that relevant team members have been involved in the analysis of the event. Consider, for instance: a lack of education and training; the need to follow systems or procedures; the vital importance of team working or effective communication.
4. What has changed? Outline the actions agreed and implemented, where this is relevant or feasible. Consider, for instance: if a protocol has been amended, updated or introduced; how was this done and who was involved; how will this change be monitored. It is also good practice to attach any documentary evidence of change, e.g. a letter of apology to a patient or a new protocol.
A good defence
If you and your team follow the seven steps and answer the four questions of the structured analysis in as much detail as is possible and practical, then you can’t go far wrong. Educational feedback adds further validity to your findings and, of course, peer review is high on the GDC’s wish list for revalidation. Make sure your SEA is relevant, full of detail and legible (ideally typed).
From a medico-legal perspective, SEAs can be very valuable. They immediately demonstrate a proactive approach to an incident or a complaint and can show how you came about whatever improvements you have subsequently made. When something has gone wrong, the production of a SEA will add to your defence by demonstrating reflection and empathy. You will be able to show how and why you have changed your protocols and reduced the risk of negative events reoccurring.
More information on SEAs can be found in section 13 of the NES Complete Audit Pack. Find out more here
David MacPherson is a Practice Development Plan (PDP) CPD tutor with NES
Pringle M, Bradley C P, Carmichael C M, Wallis H, Moore A. Significant Event Auditing. RCGP Occasional Paper 70. 1995
Bowie P, McKay J, Dalgetty E, Lough M: A qualitative study of why general practitioners may participate in significant event analysis and peer assessment. Qual Saf Health Care 2005; 14:185-9.
Bowie P, McKay J, Norrie J, Lough M. Awareness and analysis of a significant event by general practitioners: a cross sectional survey. Qual Saf Health Care 2004; 13(2):102–107