I did not see the point of critical event audit (CEA) for our practice when it was first proposed. We already had quite enough meetings, journal clubs and lectures. While the idea seemed reasonable enough – a regular interdisciplinary forum to discuss events both good and bad, with the emphasis on the systems rather than individuals, so encouraging a 'no-blame culture' – I was not convinced it was worth the effort. However, we were having trouble meeting as a whole primary care team, so it was worth a try.
CEA had been seen elsewhere by some of the team members and they were keen to see if it could work for us. We were greatly assisted by having an experienced facilitator who had set up CEAs before and so helped us avoid some of the pitfalls.
The first meeting was an eye opener for me as it became clear that this was a really useful way of dealing with both difficult and mundane issues constructively.
The turning point came when the facilitator commented, with regard to a particular problem, that we were living in an imperfect world and that the resolution we had achieved was not bad. CEA is not an ivory tower exercise imposed by academics, but a 'real world' useful tool.
We are a large practice with four surgeries, and the district nurses and other members of the team on a fifth site. There were practical difficulties of choosing a convenient time and date so we made an arbitrary choice to get things going. We settled on a doctor who had experience in this role to chair the meetings .
If a group is too big it can sometimes be hard to generate enough intimacy to allow everyone to participate actively. The first meeting attracted more than 30 people, so we split into two groups and discussed different events in each group, with a plenary session immediately afterwards. This worked well, although later it also seemed to work well with a large meeting and a single large group.
Our initial agenda was chosen carefully. We had asked the team for events and got a reasonable response once it was made clear that 'significant event' was a pretty general title.
One topic was a prescription request from district nurses that had been lost and then incorrectly written. The no-blame attitude led to useful discussion, and recognition that the problem was not that everyone involved was incompetent but that there were several points in the process where mistakes could – and therefore in the end would – happen. We agreed to fax such requests in future.
At the next meeting it was reported back that the system was in place and was working. A real source of irritation and potential disaster had been identified and dealt with and everyone was involved in it.
We realised that often we were confronted with what had gone wrong, so we made a point of also celebrating things that had gone well. Examples include successful defibrillation in the surgery car park and resuscitation of an anaphylactic patient. In both cases, administrative as well as clinical staff played a vital part.
We had input from members of the team who would not usually be forthcoming. It was refreshing to hear familiar issues discussed from different points of view. When we could all see how our actions affected others, we could all 'own' the solutions.
From our experience, these would include:
- Choose topics carefully
There must be a variety of good/ less good, clinical/administrative subjects. They can be as mundane as misfiled letters or as dramatic as a life saved. Very personal issues may not be best dealt with in a CEA, so that, for instance, complaints against an individual might be inappropriate.
- Hold regular meetings
Not so often as to be a bore, but say bi-monthly so that they are always at the back of everyone's mind and the events are still fresh.
- Make attendance as easy as possible
Many doctors and staff work part time or have other commitments, so change the days to allow for this. Give people lunch and hold the meetings in paid time.
- Separate the person from the issue
Emphasise the need to look at systems not people. Do not allow people to be scapegoats or to place themselves in that role.
- Chair carefully
The chair needs to be ready to steer the meeting away from an individual who is getting over-exposed. This might involve agreeing rules of confidentiality for the meeting in terms of place, such as the meeting room, or time. Confidentiality in time is a useful concept whereby the meeting can deal safely with issues, which are not then brought up again at a different time even among the same people.
- Minimise inequality
A strength of CEA is the potential for all team members to contribute; this may involve preventing employers from inadvertently suppressing their employees or extroverts from hogging the floor.
- Administer properly
Circulate the agenda at least 2 days before the meeting. Record outcomes and feedback from the last meeting. Ensure that named people are responsible for agreed actions so that action points can be seen to have produced results.
- Look after each other
This might be achieved by sharing good experience without any outcome expected from the meeting. At times, people may be a little vulnerable after the meeting if a difficult area is touched upon: be aware that someone might need support afterwards and that zooming straight back to work might be awkward.
Westcott et al1 discuss the benefits and hazards of CEA in greater depth. CEA is well worth the effort and can be an integral part of personal development plans and clinical governance, enabling us to demonstrate our continuing education.
- Westcott R, Sweeney G, Stead J. Significant event audit in practice: a preliminary study. Fam Pract 2000; 17: 173-9.