Investigating the investigations: a national study of Australian healthcare leaders’ views on serious adverse event investigation methods, costs and organisational challenges”

Adverse events remain a major source of preventable harm globally, with serious adverse events (SAEs) representing the most severe outcomes. Although investigation processes aim to support learning and accountability, concerns persist regarding their methodological limitations, resource burden, and impact on safety improvement. This study examined senior healthcare leaders’ perspectives on SAE investigation practices across Australian public health services, focusing on investigation methods, organisational challenges, knowledge of costs, and the role of legislated protection. A national cross-sectional survey was distributed to senior executives responsible for clinical governance across 116 Local Hospital Networks, with 59 valid responses analysed using descriptive statistics and qualitative content analysis. Root Cause Analysis remained the dominant investigation method despite widely reported limitations, including inflexibility, time burden, and variability in investigator capability. While most leaders reported access to legislated protection, its application varied, with perceived benefits for confidentiality alongside concerns about reduced organisational learning. Participants estimated an average cost of $13,219 AUD and 106 h per SAE investigation; however, 92% reported that these costs are not formally tracked. Although many viewed investigations as a worthwhile investment, over one-third reported no reduction in SAE rates, and uncertainty remained regarding the effectiveness and implementation of recommendations. As the first known national study capturing senior leaders’ perspectives on SAE investigations, including financial burden and legislated protection, these findings highlight the need for more flexible investigation models, strengthened capability, clearer guidance, and improved cost monitoring to support sustainable system improvement.