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Significant Event Audit

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SEAs involve a systematic attempt to investigate, review and learn from a single event that is deemed to be ‘significant’ by the healthcare team.
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Significant Event Audit

Reported SEA - Audit Definition of a significant event; 'Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice''.

Start date of the SEA:

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Stage 1 - Awareness and prioritising a Significant Event Audit

Does the practice have a disignated person(s) who can be consulted to make a judgement on whether a specific significant event should be formally audited immediately, or be dealt with in a simpler way?

1.1 -Name of designated person(s):

1.2 - Description of the SEA:

1.3 - SEA Category:

1.4 - Could the incidence have been prevented?

Stage 2 - Information gathering

2.1 - What happened (summary)?

2.2 - How it happened:

2.3 - Why it happened (summary):

2.4 Evidence Collected:

2.5 Evidence:

Stage 3 - The facilitated team-based meeting

3.1 - Is the SEA part of the monthly practice meetings?

3.2 - Is the meeting in addition to the routine practice meetings due to the urgency of the event?

3.3 - Is there a named nominated facilitator?

3.4 - Aims and process of the discussion:

3.5 - Summary of Findings:

Stage 4 - Analysis of the significant event

4.1 - What happened (in detail)?

4.2 - Why did it happen (in detail)?

4.2.1 - Main Reasons:

4.2.2 - Underlying Reasons:

4.3 - What has been learnt?

4.4 - Did the event occur due to a lack of knowledge and training?

4.5 - Could the event have been prevented if the system s and/or procedures?

4.6 - Was the event due to a lack of team work?

4.7 - Was the event due to a lack of effective communication?

4.8 - Has the care and service provided been shown to be exemplary (eg team-based effort in the successful resuscitation of a patient)?

4.9 - is no action required?

4.10 - Has a learning need been highlighted?

4.11 - Has a learning point been highlighted (eg a protocol which requires altering)?

4.12 - Is a conventional audit required?

4.13 - Is there a need for immediate action/change?

4.14 - Is there a need for further investigation and an in-depth SEA required (eg in the event where multiple organisations are involved)?

4.15 - is the information going to be shared?

Information to be shared with:

Stage 5 - Agree, implement and monitor change

5.1 - What actions have been agreed upon?:

5.2 - How and when will the changes be implemented?:

Select date

5.3 - How will the changes be monitored?:

Stage 6 - Write it up

Additional information not already mentioned:

Stage 7 - Report, share and review

7.1 - Is one or more of the following to receive a copy of this SEA?

7.2 - How many of the following will be sent a copy?

7.2.1 - Patient and/or carer?

7.2.2 - Educational peer reviewers?

7.2.3 - Care Quality Commission (CQC) Assessors/reviewers?

7.2.4 - General Dental Practice (GDP) appraisers?

7.2.5 - British Dental Association (BDA) Good Practice assessors?

7.2.6 - Clinical governance assessors?

7.2.7 - Primary Dental Care (PCT) Cluster assessor/advisor?

7.2.8 - General Dental Council (GDC) assessor?

7.2.9 - National Patient Safety Agency (NPSA)?

7.2.10 - Health & Safety Executive?

7.2.11 - National Radiographic Practice Board (NRPB)?

What was effective about this SEA:

(check name not set)

Completed:

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