Series 6: Learning from everything - significant event audits and root cause analysis


QI Boxset series 6 will introduce you to Significant Event Auditing (SEA) and Root Cause Analysis (RCA). In this series, you will find out how to use QI tools to investigate an event to identify what went wrong, as well as what went well. By delving deeper into the root causes, we can identify what areas could be improved, and how to put steps in place to avoid errors reoccurring. These tools break down the steps from start to finish so that you can reflect and share learning to improve the quality of care. The series is arranged into episodes, each one including information and multimedia to support your learning.


The QI Boxset will help you learn about Quality Improvement with small bite-sized episodes. Just like streaming services, you can work your way through each episode or scroll to pick and choose what you want to watch, read or listen to.


Course image Episode 1: Dealing with errors in practice - why we need significant event auditing
Series 6: Learning from everything - Significant event audit and root cause analysis
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Description:

Find out what significant event audits are, how they can benefit practice teams, and why they are important to help reduce avoidable errors, improve outcomes, and help ensure the safety of our patients.

CPD: 1 hour 45 minutes
Authors: Pam Mosedale, Mark Turner, Lizzie Lockett
Course image Episode 2: What is a Significant Event Audit (SEA)?
Series 6: Learning from everything - Significant event audit and root cause analysis
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Description:

This episode is a comprehensive guide to getting started with significant event audits. Learn how to carry out a significant event audit, step by step, to investigate when things don't go well, and when they do. 

CPD: 20 minutes
Authors: RCVS Knowledge Quality Improvement Advisory Board
Course image Episode 3: Getting to the root of the problem
Series 6: Learning from everything - Significant event audit and root cause analysis
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Description:

Learn how to use root cause analysis and other QI tools to discover the contributing factors that led to a significant event happening. Discover how to turn that learning into action to help prevent undesirable outcomes from happening again.

CPD: 20 minutes
Authors: Pam Mosedale, RCVS Knowledge Quality Improvement Advisory Board, Harvard University Online
Course image Episode 4: Learning from everything
Series 6: Learning from everything - Significant event audit and root cause analysis
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Description:

This episode covers the other QI tools that are available to help create an open, psychologically safe environment. Learn why it is important to involve the whole team in the process of investigating when things don't go well, and when they do, so everyone feels empowered to speak up and we truly can learn from everything to improve outcomes and safety for both our patients and our teams.

CPD: 2 hours 25 minutes
Authors: Pam Mosedale, Kathrine Blackie, Emma Cathcart, Amy Martin, Sara Jackson, Helen Silver-MacMahon, Andy Fisk-Jackson
Course image Episode 5: Case examples
Series 6: Learning from everything - Significant event audit and root cause analysis
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Description:

This is a library of all RCVS Knowledge’s significant event audit case examples. Here you will find both fictional scenarios and real practice significant event audits kindly shared so that we can learn from their experiences. Please choose the examples you’d like to read that are most relatable to your setting.

CPD: 4 hours 30 minutes
Authors: RCVS Knowledge Case Example Working Party, Alice Bird, Sandra Hunt, Pam Mosedale, Elisa Best, Amelia Poole