22 Jul 2019
RCVS Knowledge, the charity advancing veterinary care quality, introduces a series of case examples to detail this type of audit process and the stages involved in practice.
RCVS Knowledge
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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.
An SEA is completed in six stages. The following explains these steps required to perform one.
Create a brief description of the event, context and outcome to be discussed in the meeting.
Gather all relevant information, such as files and staff accounts, that contribute to the case.
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.
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.
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.
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.
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.
Practice: QI Vets
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.
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.
Causal factors were as follows.
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.
The following changes were made.
No official training required; however, discussion of the team’s learnings took place.
A follow-up date of 29 June 2019 was decided.
To recap, the following SEA stages were carried out.
