Significant Event Audit Case Example: An anaesthetic circuit error

After an anaesthetic error was 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.

Key takeaways

• Value of a blame-free team culture: Conducting a Significant Event Audit (SEA) in a blame-free environment enabled open discussion, identification of contributing factors (human and system-related), and collaborative learning. This approach fosters a culture of safety and continuous improvement.
• Implementation of safety protocols: As a result of the SEA, the team reinforced the use of the surgical safety checklist and committed to further audits. This demonstrates how SEAs can lead to actionable changes that enhance clinical practice and reduce future risks.

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.