Significant event audit case example: A post-operative complication

After an abscess developed 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.

Key takeaways

• Structured reflection enhances learning: Significant event audits (SEA) provide a structured approach to identifying, analysing, and learning from clinical events. This structure ensures that learning is actionable and leads to measurable improvements.

• Multifactorial analysis improves insight: Events are examined at the system, human, patient, and communication factors, allowing for a deeper understanding of root causes and contributing elements.
• Protocol enhancement for safer practice: As a result of the audit, the surgical checklist was updated to include prompts for pre-, peri-, and post-operative medication discussions. This change aimed to prevent similar events from occurring and improve communication and consistency in surgical care.

Download the PDF and read the case example to get deeper insights into the methods and outcomes, and to apply these strategies in your own practice to enhance patient safety and care.