Investigating the investigations: senior healthcare leaders’ perspectives on the organisational value, burden and effectiveness of serious adverse event investigations

Abstract

Purpose Serious adverse event (SAE) investigations are a routine feature of healthcare quality assurance, although concerns persist regarding their effectiveness, known costs and contribution to organisational learning. This study explores senior healthcare leaders’ perspectives on SAE investigation practices within Australian public healthcare organisations, with a focus on organisational value, resource implications, costs incurred to conduct and the impact of legislated protection. Design/methodology/approach Semi-structured interviews were conducted with 15 senior healthcare leaders across four Australian jurisdictions. Data were analysed using reflexive thematic analysis. Findings Leaders reflected on SAE investigations methods as complex processes that balance investigation, quality assurance and accountability, yet deliver mixed outcomes in terms of prevention, often characterised by repetitive recommendations and limited dissemination of learning. Despite their perceived value in providing organisational assurance, investigations were described as costly due to heavy reliance on senior medical staff, with legislated protection facilitating openness while simultaneously limiting transparency and sharing of organisational learning. Research limitations/implications Reporting leaders’ perceptions of how these system pressures and governance arrangements shape investigation processes and the use of findings, this study contributes new knowledge to debates on safety governance and organisational learning in complex healthcare organisations. Practical implications Healthcare leaders could consider more flexible, proportionate investigation methods, invest in investigator capability, clarify guidance on legislated protection and systematically monitor investigation costs and outcomes to support sustainable commissioning of these investigations. Originality/value This study offers original qualitative insight into senior healthcare leaders’ experiences of SAE investigations within Australian public health systems. Through in-depth interviews, it extends a literature dominated by quantitative and method-focused studies by examining how investigations are understood, governed, and enacted in practice. The findings illuminate the leadership work involved in balancing accountability, organisational learning, ethical obligations, and resource constraints. By revealing how system pressures and governance arrangements shape investigation processes and the use of findings, this study contributes new knowledge to debates on safety governance and organisational learning in complex healthcare organisations.