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Significant event audit

Our free resources will introduce you to different QI techniques, and help you understand the processes you can put in place to help improve outcomes.

Significant Event Audit CPD Course (CPD: 20 minutes)

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Tools to assist in significant event audit meetings

A handy infographic that explains the process of a significant event audit. Ideal to print! [PDF 159KB] (Updated August 2019).

You can use this template to structure your significant event audit. Once downloaded, please 'save as' and reopen from your saved location [Word 41KB] (Updated July 2019).

This document discusses root cause analysis, the 5 whys, contributory factors checklists and the cause and effect diagram. Using a clinical example you can see how these tools can find the true cause of a significant event in practice and help steer your team away from a blame culture [PDF 2114KB] (Published January 2020). 

You can use this checklist to assist in significant event audit meetings, to help identify the root cause of an event. Once downloaded, please 'save as' and reopen from your saved location [Word 41KB] (Published February 2019).

When undertaking a significant event audit, this diagram can help your team find the possible root cause(s) of a problem. Once downloaded, please 'save as' and reopen from saved location [Word 104KB] (Updated June 2020).

What this video for tips on how to use our template to find possible root cause(s) of a problem.

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Significant Event Audit Case Examples

Anaesthesia and surgery

After a team lost a rabbit patient under anaesthetic, they perform a significant event audit to find out what happened and see if processes can be changed to help prevent it from reoccurring [PDF 511KB] (Published November 2019). 

Elisa Best created a sealed emergency 'BOAS box' to be prepared for a BOAS patient in crisis. This case example details the steps into creating and implementing box within the practice [PDF 842KB] (Published June 2019).

Find a summary of brachycephalic anaesthesia in InFocus.  

This case example details a significant event audit that was completed in practice after a patient received an opioid overdose. It is useful to see the steps undertaken to complete the audit, and what information was discovered that lead to the cause of the event [PDF 180KB] (Published March 2019).

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Inpatient care

This case example details how a practice team reacted after a patient escaped while trying to maintain social distancing during COVID-19 [PDF 516KB (Published April 2020).

This case example details a significant event audit that was completed in practice after a patient deteriorated and cardiopulmonary resuscitation was required. It is useful to see the steps the team took to provide care to the patient and each other, as well as the processes that were in place to help [PDF 499KB] (Published June 2019).

This case example details a significant event audit that was completed at a mock veterinary practice 'QI Vets'. The first of our features in Vet Times looks at how the team took action after a kitten suffered from fluid overload [PDF 500KB] (Published July 2019).

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Pharmacy

This case example details a significant event audit that was completed at a mock veterinary practice 'QI Vets'. The second of our features in Veterinary Times looks at how the team took action after it was discovered there was less methadone in stock than recorded in the controlled drugs register [PDF 600KB] (Published November 2019).

When on a visit to a well-known client and her horse, the team realise that a sedative has been administered instead of a local anaesthetic. This case example shows how the incident was examined, and what procedures were put in place to prevent the same thing happening to another patient [PDF 611KB] (Published April 2020).

The team discuss their systems of work after a near miss is reported in the dispensary. This case example shows the processes that were put in place to prevent the error from occurring again [PDF 618KB] (Published August 2020). 

A patient is admitted after being given a 45kg dose of meloxicam instead of a 4.5kg dose. This case example shows the processes the team took to identify how this happened, and how to change to improve patient safety [519KB] (Published September 2020)

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Updated 10/9/2020