What techniques are appropriate to analyse patient care and methods of working? Two readers contribute to the debate

We disagree with the answer to the question ‘What is the difference between a critical incident audit and a significant event audit?’ (‘Your problems solved: audit’ Guidelines in Practice Feb 2003).

First, significant event audit (SEA)1 developed from a marriage of single case review with the philosophy and principles that underpin the critical incident technique.2 This provides SEA with a simple structure to follow and a degree of scientific rigour not necessarily present in largely informal case review discussions. The structured analysis of a significant event involves gaining insight into the event and learning from it, implementing change (where appropriate) and minimising the chance of recurrence.

The critical incident technique is a recognised qualitative research method, used for a variety of purposes in different settings, and which has occasionally been applied to facilitate qualitative audit studies.

Variations of the term and technique (e.g. critical event audit/monitoring and critical incident analysis) appear in the literature, but these published methods do not appear to share the structured approach to audit of SEA. In addition, the term ‘critical incident’ has been criticised because of its pejo-rative nature and its potential to mislead when used in a clinical context.1

Second, the answer states "in both audits, you define a situation that merits attention ... when this situation occurs, the care of the patient is reviewed.” Although practitioners are encouraged to adopt this approach as a useful starting point for pre-defined cases, such as suicides or newly diagnosed cancers, we believe it is quite restrictive given the complexity and uncertainty of modern healthcare.

A more flexible approach, in which events considered significant are identified and prioritised may be more useful. In general practice there is a lack of evidence about the range and types of significant events that occur to allow many events worthy of analysis to be predefined or categorised conveniently.

Another point worth making is that it is not only patient care which can be reviewed, but also important administrative or organisational procedures that can be highlighted and analysed.3

Finally, it is implied that a significant event is "not necessarily so dramatic” [as a critical event]. While we agree that the SEA technique encourages practitioners to highlight and learn from examples of good practice, the prefix ‘significant’ is an umbrella term that is commonly applied to events or incidents that could be described as critical, adverse, near misses or errors.4

However, anecdotal evidence from our own database of around 500 significant event analyses submitted by GPs for educational peer assessment, suggests that most deal with negative incidents that could fall into the categories outlined. Recent focus group work with these GPs has confirmed that ‘positive’ events are rarely if ever identified for analysis.

This profusion of terminology, and the potential for misinterpretation, only adds to the confusion in this complex subject area. However, in general practice, ‘significant event’ appears to be supplanting ‘critical incident’ and other related terminology as the phrase of choice when dealing with these issues. In addition, significant event audit (or analysis!) is highly likely to be the most common method of qualitative audit undertaken.

Paul Bowie, Associate Adviser
Dr John McKay, GP/Associate Adviser
West of Scotland Region,
NHS Education for Scotland


  1. Pringle M, Bradley CP, Carmichael CM et al. Significant event auditing: A study of the feasibility and potential of case-based auditing in primary medical care. Occasional Paper 70, Royal College of General Practitioners. London, 1995.
  2. Flanagan JC. The critical incident technique. Psychol Bull 1954; 51: 327-58.
  3. McKay J, Bowie P, Lough M. Evaluating significant event analyses: implementing change is a measure of success. Education for Primary Care 2003; 14(1): 34-8.
  4. Harrison P, Joesbury H, Martin D et al. Significant event audit and reporting in general practice. Commissioned Report by the School of Health and Related Research, University of Sheffield, 2002. http://www.shef.ac.uk/uni/academic/R-Z/scharr/ (accessed 27th December 2002).

Guidelines in Practice, April 2003, Volume 6(4)
© 2003 MGP Ltd
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