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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

Stop5 or ‘Stop for 5 Minutes’ is a hot debrief framework that can be led by any member of the resuscitation team. The purpose of this confidential, blame free, team debrief is to improve patient care and to deliver timely support to team members after difficult or distressing clinical cases. Find out more in our new QI feature, When it all goes wrong: the importance of debrief.

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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This document included examples of Quality Improvement principles and tools which can be implemented within your practice to form your clinical governance plan. You should adapt this for your own practice, or local circumstances. Once downloaded, please 'save as' and reopen from your saved location [Word Doc 174KB] (Published July 2021).

Significant Event Audit Case Examples

Anaesthesia and surgery

After an anaesthetic error is identified, Sandra Hunt and the team from The Laurels performed a significant event audit to identify what happened. This significant event audit was part of a case example that was awarded Highly Commended in the 2020 Knowledge Awards [PDF 705kb] (Published November 2020).

After an abscess develops on an enucleation site, Sandra Hunt and the team from The Laurels performed a significant event audit to identify what happened. This significant event audit was part of a case example that was awarded Highly Commended in the 2020 Knowledge Awards [PDF 191KB] (Published November 2020).

After a wound breaks down post-operatively, Sandra Hunt and the team from The Laurels performed a significant event audit to identify what happened. This significant event audit was part of a case example that was awarded Highly Commended in the 2020 Knowledge Awards [PDF 889KB] (Published November 2020).

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

After a patient is given the wrong type of saline on admission, the team perform a significant event audit to find out what happened, and how they could avoid the event from reoccurring [PDF 207KB] (Published December 2020).

You can also read the case in Vet Times.

RCVS Knowledge (2020). Significant event audit: incorrect saline type. Vet Times, 50 (49)

After returning from furlough, the team are overwhelmed and a patient receives the wrong dose of a pre-medication.
This case example shows how the team analysed what had happened and the process they put in place to reduce the risk of other team members making the same error.

You can also read the case in Vet Times.

RCVS Knowledge (2021). Significant event audit: drug calculation error. Vet Times, 51 (6)

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

After a bulk tank failure after a case of mastitis, the QI Vets team perform a Significant Event Audit to identify what happened [PDF 206KB] (Published December 2020).

You can also read the case in Vet Times

RCVS Knowledge (2020) Significant event auditing part 6. Vet Times, 50 (46)

This time, a medication is prescribed without obtaining informed consent. This case example will go into more detail about what happened and what the practice did as a result [PDF 503KB] (Published March 2021).

You can also read the case in Vet Times

RCVS Knowledge (2020) Significant event auditing part 7. Vet Times, 51 (4)

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 [PDF 519KB] (Published September 2020)

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Updated 13/08/2021