Serious Adverse Event Review (SAER)

Serious Adverse Event Review (SAER) Data

In line with the NSW Health Incident Management Policy, a SAER is required to review all Harm Score 1 and selected Harm Score 2 - 4 Reportable Incident Briefs (RIBs). SAER reports are due for submission to the Ministry of Health within 60 days of notification for all NSW public hospitals. Private hospitals are required to submit their SAER reports within 100 days.

There are four types of SAERs that can be used to investigate serious clinical incidents:

  • Concise Incident Analysis
  • Comprehensive Incident Analysis
  • London Protocol, and
  • Root Cause Analysis (RCA).

Further information on these methodologies can be found on the CEC website.

The CEC undertakes a review of each SAER report submitted through one the sub-committees of the Statewide Clinical Risk Action Group (CRAG). The sub-committees classify each report using a standard classification system to identify learnings and develop system improvements across the health system to prevent similar incidents occurring again. The classification system is revised as new issues and clinical practice changes are identified. The sub-committees also review and confirm potential Australian Sentinel Events. An overview of the sub-committees is provided on the CEC website.

The CEC's standard classification system is comprised of:

Human Factors

This is an evidence-based scientific discipline that applies what is known about human capabilities and limitations to the design of systems, processes, and environments to maximise human potential in the environment and to reduce the likelihood of harm. The intent of taking a human factors approach is to create a system where doing the right thing becomes easier. An understanding of human factors can help health professionals to:

  • Enhance safety
  • Reduce error
  • Enhance personal wellbeing
  • Perform efficiently.

"Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings." Dr Ken Catchpole

Across the July – December 2021 reporting period, the classification of SAER reports identified the following human factors elements as most commonly contributing to patient harm across the SAER/SIR sub-committees:

  • Loss of situation awareness, by focusing on one aspect of care or irrelevant information
  • Cognitive behaviour, relates to the failure to act appropriately on available information despite adequate knowledge and training
  • Knowledge based errors, caused by gaps in skills or knowledge.

Risk Factors

Clinical risk factors relate to conditions or situations that are considered a direct cause, or contributing factor, to the outcome of an incident. A single SAER can identify multiple risk factors.

During the reporting period of July - December 2021, the overall top risk factors identified by the review sub-committees related to:

  • Physical co-morbidities
  • COVID-19
  • Deteriorating patient – failure to recognise.

System Factors

System factors can contribute to, and impact upon patient safety. By identifying and understanding these system factors, NSW Health can take appropriate action to address and respond through the dissemination of learnings and developing initiatives that can impact health care.

During the reporting period of July - December 2021, the overall top system factors identified by the review sub-committees related to Care Planning and Communication.

SAER Review Sub-Committee activity at a glance

Snapshot of SAER SIR Sub-Committee