Department of Health

Clinical incident investigations - in-depth case review

Key messages

  • Clinical incidents with a severity rating of ISR 2 are reviewed using in-depth case review methodology.
  • In-depth case reviews can identify system problems that then lead to system improvement initiatives.

An in-depth case review is a detailed and thorough investigation similar to the root cause analysis (RCA) but is less resource intensive. It can be undertaken by a team of two, but it should be led by a senior manger.

An in-depth case review investigates clinical incidents to identify process and system issues. 

The review identifies what happened, why the incident occurred and what can be done to prevent it from happening again.

When to conduct an in-depth case review

The methodology should be used for a valid clinical incident with an ISR 2.

It may also be used to review incidents with an ISR 3 or 4.

The Department of Health & Human Services expects all completed ISR 2 case reviews to be submitted to the health service’s clinical governance committee for consideration.

When not to conduct an in-depth case review

This methodology is not used for performance management related issues or any incident that is subject to review under the state or Commonwealth criminal justice system.

Reviewed 01 March 2022

Health.vic

Contact details

Postal address: GPO Box 4541, Melbourne VIC 3001

Quality and Safety Branch Department of Health

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