A 32-year-old patient with type 1 diabetes who is on your clinic list is admitted with sudden loss of vision. You
decide to examine the events which led up to this as part of a significant event audit.
Which of the following is part of the process of significant event audit?
Agreement, implementation and monitoring of necessary changes is an essential part of the process Correct
Events cannot be reported as part of the QAOF
Events should not be reported to the National Patient Safety Agency, (NPSA)
Non-clinical staff should be excluded from the review process
Sudden loss of vision in a diabetic would not normally constitute a critical event
As in all audits, agreement of an endorsement for change is an essential part of the process. If problems in this case with current review or scheduling of appointments for retinal photography are identified for example, then changes may be required.
Events should be reported to the NPSA and may be included as part of the QAOF (quality and outcomes
framework). Sudden and unexpected loss of vision in a diabetic is of course a critical incident. Whilst patient’s
vision may deteriorate over time, sudden visual loss, whilst it does occur, would not be considered the norm.
Non-clinical staff and their working procedures may be an underlying cause of a critical incident; as such their
inclusion in the process is crucial.