Lookback review

A lookback review process is triggered when a group of patients are affected by a cluster incident.

A cluster incident is a type of adverse incident where there is a group or series of harmful incidents that are the result of one systemic error or issue, and that involves a systems failure or multiple systems failure that does or has the potential to place more than five patients directly at risk.

The lookback review process involves:

  • identifying, tracing, communicating, and providing appropriate ongoing advice to, and/or management of, the group of patients.
  • notification to appropriate external bodies, senior management and executives of the Health Service, and the Department for Health and Ageing.
  • establishment and implementation of a coordinated plan for review, investigation and determining recommended actions to prevent recurrence.
  • formation of a communication strategy, including notification to the general public, where appropriate.

Detail of the process to be followed during a lookback review is provided in the Lookback Review Policy Directive (PDF 508KB).

A lookback review action plan template will be available to assist the review team.

For further information, see  Patient Incident Management and Open Disclosure.


Clinical Governance Unit
Email: Health.DHWClinicalGovernanceEnquiries@sa.gov.au
Telephone: (08) 8226 6334