Children and Young Person SAER Review Sub-Committee

The Children and Young Person sub-committee is responsible for reviewing and analysing all children and young person related Serious Adverse Event Review (SAER) reports for the purpose of identifying statewide patient safety issues and key learnings.

During the reporting period, a total of 9 SAER reports were reviewed by the sub-committee. Due to the small number of reports received and reviewed, SAER classifications reflect the most selected categories.

The top selected human factors related to:

• Cognitive based errors, involving the failure to understand, process or act appropriately on available information despite adequate education and knowledge
• Loss of situation awareness, relating to the fixation on irrelevant information, poor prioritisation and planning of care.

The top selected risk factors include:

• Deteriorating patient – failure to recognise, where deterioration of the child/young person was not recognised
• Diagnostic error, relates to issues associated with an error in diagnosis.

An overview of Children and Young Person classifications is provided below.

Figure 15.

*Multiple factors can be applied to each SAER

System factors identified within Children and Young Person SAER reports predominately relate to:

• Communication, including inadequate information/communication between care providers
• Care Planning, including care coordination, resulting in difficulties in organising or planning care within or between teams or services to ensure timely patient care.

Figure 16.

*Multiple factors can be applied to each SAER