Lookback Investigations

What are they?

If there has been a breakdown in an infection prevention and control procedure or protocol, a 'lookback' investigation may be necessary to rule out the transmission of an infectious disease through complications, errors due to medical devices or products, or outbreaks with pathogenic organisms. An initial assessment is made to inform a risk assessment and response.

The following process is initiated

Notify resident

Form a local committee

Report to public health unit if appropriate (see Notifiable Diseases)

Report the incident to the Clinical Excellence Commission (CEC) if appropriate




Provide and manage advice to affected residents


Monitoring of critical incidents and other sentinel events is an important part of surveillance. A structured process should be undertaken to identify the problem and contributing factors, explore and identify risk reduction strategies, and implement solutions.