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 incident that has, or could have (near miss), caused serious harm or death; and which is attributed to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.

As outlined in the Clinical Incident Management Policy 2019 the key timeframes are:

  • to submit completed investigation reports which are due within 28 working days of notification to the Patient Safety Surveillance Unit
  • all SAC 1 recommendations must be both implemented and evaluated within six months (182 calendar days) of the investigation report submission
  • an evaluation of SAC 1 recommendations must also be forwarded to PSSU within those six months (182 calendar days) of the investigation report submission.

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
Last reviewed: 27-07-2021
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Patient Safety Surveillance Unit