COVID-19 SIR Sub-Committee

Since the COVID-19 pandemic was declared on 22 March 2020, NSW Health has provided extensive direction and support for a statewide public health response. The arrival of the Delta variant of the SARS-CoV-2 in NSW in May 2021 presented unique challenges to health and aged care facilities due to high morbidity and mortality of this variant.

The COVID-19 Serious Incident Review (SIR) sub-committee was established in late 2021, to review COVID related cases reported during July – December 2021.

This sub-committee is responsible for the review and analysis of COVID-19 SAER reports relating to outbreaks and reportable patient deaths, to identify key learnings, meeting risks and patient safety issues that have state-wide implications. Like the other SAER/SIR sub-committees of the Clinical Risk Action Group (CRAG), SAER reports referred to the COVID-19 SIR are classified according to a standardised taxonomy.

A total of 65 SAER reports were reviewed by the sub-committee during the reporting period. The main human factor elements identified within these cases related to:

No human factors identified, following review of the SAER report
Loss of situation awareness, relating to the fixation on irrelevant information, poor prioritisation and planning of care
Cognitive based errors, involving the failure to understand, process or act appropriately on available information despite adequate education and knowledge.
Skill-based – poor task execution, relating to failures in carrying out actions of a task, where the process was correct, but the execution was not
Knowledge based errors, caused by gaps in skills or knowledge

The top 5 clinical risk factors that were considered a direct cause, or contributing factor, to the outcome of an incident related to:

COVID-19, where the incident was directly impacted by or precautions relating to COVID-19
Comorbidities – Physical, refers to the presence of two or more overlapping conditions in the same person
Healthcare associated infection/multi-drug resistant organism (MRO), relates to infections acquired within in healthcare facilities
Confusion / Delirium, where a patient experiences disturbances, attention cognition and perception that developed over a short period of time (usually hours or days)
Acute coronary syndrome (ACS), the spectrum of acute clinical presentations resulting from underlying coronary heart disease, including heart attack and angina.

An overview of COVID-19 classifications are provided below.

Figure 17.

Figure 17 - COVID-19 SIR Classifications

*Multiple factors can be applied to each SAER

System factors identified within the COVID-19 SAER reports predominately related to:

Care Planning, including difficulties in organising care and high risk factors not identified or acted upon
Communication, including inadequate information between care providers
Environment, including physical surrounds (e.g. poor line of sight and cluttered areas).

Figure 18.

Figure 18 - COVID-19 SIR system factors

*Multiple factors can be applied to each SAER