Joined up Clinical Governance: Learning from Our Mistakes

  • Pam Mosedale Royal College of Veterinary Surgeons, Belgravia House, 62-64 Horseferry Road, London, SW1P 2AF



Open Access Logo



This session will be a practical demonstration, with group discussion of how a significant event can lead to the practice examining what happened, looking at the evidence base, revising protocols & auditing implementation of the new protocols.

A significant event is an event thought by anyone in the team to be significant in the care of patients or the conduct of the practice.
Significant Event Audit is a qualitative rather than quantitative form of Audit but still needs a structured framework to be successful.
SEA involves gathering information in the form of a timeline of the event, clinical records & accounts of individuals involved.
Scenarios around significant events will be discussed and analysed by the group as if they were conducting a non-threatening, open, fair & honest SEA meeting.

During the meeting the incident will be analysed to see what happened, why it happened, any underlying reasons, what has been learned & what needs to change. This meeting is not to apportion blame.

When looking at what needs to change the group should consider whether it is necessary to go away & look at the evidence base & then make changes to practice protocols. Any need for training or CPD for individuals or the whole team should be identified.
A timescale for changes should be agreed.

An audit can then be carried out to monitor the improvements and assess the impact of these changes. The group will consider what audits are appropriate, whether process or outcome audits are useful in the circumstances. They will also discuss how these audits can be carried out.

SEA is a very useful tool in veterinary practice & a very good way to get all team members engaged with clinical governance & evidence based veterinary medicine in a joined up way which demonstrates the potential improvements to practice systems of work and patient care and safety.

This session would be designed to appeal to all team members whether vets, nurses, receptionists or practice managers.