Closing the Loop Program

The Closing the Loop Program is focussed on the implementation and enhancement of severity assessment code 1 (SAC 1) clinical incident management, specifically the:
  1. Development and implementation of recommendations and
  2. Evaluation of recommendations.

The Closing the Loop Program aims to progress the safety and quality culture within WA Health with regard to the Clinical Incident Management (CIM) process and is an integral part of ensuring that lessons are learnt from clinical incidents so that improvements in health care delivery and patient care are achieved.

SAC 1 clinical incidents include all clinical incidents/near misses where serious harm or death is/could be specifically caused by health care rather than the patient’s underlying condition or illness. In WA, SAC 1 also includes the 8 nationally endorsed sentinel event categories.

As outlined in the Clinical Incident Management Policy, the key timeframes to

  • complete investigations and develop recommendations into SAC1 clinical incidents is 28 working days and
  • the subsequent implementation and evaluation of recommendations is six months from the submission of the incident investigation report.

The Closing the Loop Program includes resources and processes to assist health services with understanding and meeting these SAC1 investigation and evaluation requirements including how to develop strong, sustainable recommendations and what methods can be used to evaluate if these recommendations are working to reduce preventable harm.



Action Plan




More information

Patient Safety Surveillance Unit