This book is a welcome addition to those currently available in the sphere of health‐care quality assurance and clinical governance in particular. Its layout is particularly eye‐catching with each of the chapters broken down into bullet points with good use made of subheadings, numbering of points, flow charts, diagrams and tables. The “main points of the news” are written in italic script and shaded, to enable the reader who may have limited time available to “dip in and out” of chapters to review points.
Clinical governance is firmly upon everyone’s agenda working in the field of health care, whether in hospital or the community. If clinical governance is going to make a difference by improving health care for all who use the health‐care system, the best use of appropriate methodologies must be made. Significant event audit (SEA) is a methodology that can be used to great effect to “flag up” excellence in care. The authors give several examples of significant events, one of which was how good teamwork brought about a good outcome for a patient who became seriously ill whilst in the practice reception area. This enabled the staff to highlight and meet a training need, which had not been considered previously.
For readers new to the concept of SEA the authors start by making the links to clinical governance and highlight that it is not just another meeting to look for someone to blame for the errors that inevitably happen in busy organisations treating large volumes of patients. They believe that an investment in SEA of one hour a month (to which they refer as the “golden hour”) is repaid by reducing the likelihood of litigation by putting safer systems in place, by team building within a no‐blame culture and by enhancing the quality of care.
Chapter 2 gives simple rules for participants to follow when embarking upon SEA and gives real life examples of problems that have been solved by this process, the majority of which were not significant in the true sense of the word, but little problems that were solved by the team discussing them and a solution being found. It is heartening to see the authors highlighting congratulations as the most important outcome of success and, as they point out, “there is no history of praising people or teams about good aspects of care” – sad but true.
Chapter 3 explores the origins and development of SEA and, perhaps more importantly, what SEA is not! It also gives examples of some of the key lessons that have been learned as a result of the process.
Chapter 4 makes the links between SEA, learning and improving and utilises Nolan’s three “very important fundamental questions” to illustrate their point. However, I could not find any reference to the work of Nolan in the reference and bibliography section of the book.
Chapter 5 revisits the ground rules and gives tips on how to maintain SEA six months down the road, when enthusiasm may be waning.
In chapter 6 the background to SEA and adverse incident reporting are explored with reference to the work of Professor Liam Donaldson, An Organisation with a Memory. The emphasis is placed on getting the culture right within the organisation, to enable health‐care professionals to report incidents without fear of disciplinary action, unless of course it is necessary.
Chapters 7‐11 give real examples of SEA in action in a variety of clinical situations, primary care, hospital and the prison service. Several case studies are presented with solutions generated, outcome categories identified and conclusions drawn, leaving the reader feeling that they too could make a difference for patients using SEA.
This is a very readable book for health‐care professionals in all areas of clinical practice. It has a variety of resources listed including teaching materials and I would recommend it to all readers interested in quality improvement in health care.
