Experience Summary

In this experience, watch as a senior colleague debriefs a challenging shift and a subsequent significant adverse event review (SAER) with a junior colleague.

The shift in question was extremely busy and understaffed, resulting in the junior neglecting routine jobs that were handed over. One such job was to check a Computed Tomography Pulmonary Angiography (CTPA) report for a patient. As part of the shift, the patient suffered a cardiac arrest, having been found to have a pulmonary embolism on the CTPA. The patient died and as a consequence a SAER will be taking place.

Clinical Context

A SAER is a structured process used to investigate incidents that have resulted in, or had the potential to result in, significant harm to a patient. The purpose of a SAER is not to attribute blame, but to understand what happened, why it happened, and how learning can be used to improve patient safety and reduce the likelihood of similar events occurring in the future. SAERs form an important part of clinical governance and promote a culture of openness, reflection, and continuous quality improvement.

A SAER should be initiated following serious patient safety incidents, unexpected deaths, diagnostic delays, medication errors, or other events where there is significant learning potential. The review is conducted by a multidisciplinary team and aims to establish a clear chronology of events, identify contributory factors, and determine whether systems, processes, communication, or human factors influenced the outcome.
The review process involves collecting relevant clinical information, reviewing documentation, interviewing staff involved where appropriate, and analysing both the immediate and underlying causes of the incident. Rather than focusing solely on individual actions, SAERs use a systems-based approach to identify opportunities for improvement. Findings are translated into practical recommendations with clearly defined actions, responsibilities, and timescales. These actions should be monitored to ensure that improvements are implemented and sustained.
An important component of a SAER is involving patients and, where appropriate, their families in accordance with the principles of Duty of Candour. Honest communication, timely explanations, and apologies where appropriate help maintain trust and demonstrate organisational transparency. Reflecting on adverse events also supports professional development by encouraging healthcare teams to learn from mistakes and share good practice across services. By identifying contributory factors and implementing meaningful changes, Significant Adverse Event Reviews strengthen patient safety, improve the quality of care, and foster a culture of learning rather than blame. Effective SAERs ensure that lessons from adverse events lead to measurable improvements in healthcare systems and better outcomes for future patients.

Learning Outcomes

1. Understand the purpose of a significant adverse event review (SAER).
2. Understand the process of taking part in a SAER.
3. Observe a discussion regarding a SEAR.

External Resources

• A National Framework for Reviewing and Learning from Adverse Events in NHS Scotland - Healthcare Improvement Scotland
• SAER information for patients and relatives - NHS Scotland