Serious incident reviews
To focus on timely review of incidents and to enable timely feedback to the healthcare system, the CEC has six Serious Incident Review (SIR) sub-committees which are sub-committee of, and report to, the Clinical Risk Advisory Group (CRAG).
These sub-committees have statutory privilege under section 23 of the Health Administration Act 1982. In line with the CRAG's Terms of Reference, documents created by and for the sub-committees are privileged and cannot be disclosed or released without the approval of CRAG.
The SIR Sub-committees of the CRAG review all clinical Serious Adverse Event Review reports for classification, theming and analysis to identify system wide learning and risks.
Information on the analysis of SIRs.
Learnings publications
Lessons for Learning - Diagnostic Error - January 2026
Lessons for Learning - Chest Pain - January 2026
Lessons for Learning - Bowel Obstruction - September 2025
Patient Safety Watch - Alarm fatigue in cardiac monitoring - December 2024
Patient Safety Watch - Harm caused by omitting anticoagulants - October 2024
Clinical Management Watch - Nasogastric tube insertion and management - October 2023
Key Messages - Clinical Management - October to December 2022
Lessons for Learning - COVID-19 - IPAC Fundamentals - May 2023
Maternal and Perinatal Watch - Neonatal Sepsis - April 2026
Learnings Summary – July to December 2025
Learnings Summary – January to June 2025
Learnings Summary – July to December 2024
Maternal and Perinatal Watch - Uterine rupture - November 2024
Learnings Summary – January to June 2024
Learnings Summary – January to December 2023
Lessons for Learning - Emergency Caesarean Sections - November 2023
Maternal and Perinatal Watch - Reducing Stillbirth - May 2023
Learnings Summary: October - December 2025
Lessons and Learnings: Older Persons - January 2026
Learnings Summary: July - September 2025
Learnings Summary - April - June 2025
Lessons and learnings – Safety planning - November 2025
Learnings Summary - February – March 2025
Learnings Summary - October – December 2024
Lessons and Learnings - Responding to physical health deterioration - March 2025
Learnings Summary - July - September 2024
Lessons and Learnings - Managing alcohol withdrawal - December 2024
Lessons and Learnings - Care planning - October 2024
Learnings Summary - April - June 2024
Lessons and Learning - Escalating care - September 2024
Learnings Summary - February - March 2024
Lessons and Learnings - Voluntary presentation does not equate to lower risk - May 2024
Lessons and Learning - Care of consumers detailed under the Mental Health Act - November 2023
Lessons and Learning - Engagement with GPs and Collaborative Care Planning - May 2023
Lessons and Learning - Stimulants as a Red Flag and Physical Health Screening - July 2023
