Australian Capital Territory Audit of Surgical Mortality


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Qualified privilege
Audit process
ANZCA process
Frequently asked questions
Electronic platform - Fellows interface
Submission for Data Request
Reports and publications
Case Note Review
Committee Meeting Dates


The ACT Audit of Surgical Mortality (ACTASM) is an audit process that provides an independent, external peer review, which is systematic, objective and confidential. The purpose of ACTASM is to review all deaths that occur during an episode of surgical care and to provide opportunities for improvements in patient outcomes.

ACTASM is an important initiative of the Royal Australasian College of Surgeons and is modelled on the successful Australian New Zealand Audit of Surgical Mortality (ANZASM). ACTASM is funded by ACT Health to provide the audit process to all public and private locations in the ACT under Commonwealth Qualified Privilege. The ACTASM Management Committee meets quarterly and oversees the project which constitutes an invaluable foundation to the running and success of the audit program.

Clinical audit

Clinical audit is a regular, documented, critical analysis of the outcomes of (surgical) care. It is accepted as an essential component of the evidence-base that underpins the practice of surgery.

This audit process is designed to gather information on factors involved in the death of patients undergoing surgical treatment. Gathering information from multiple sources over time, will allow detection of system issues and emerging trends.

The aim is to develop strategies to redress these through feedback to individual surgeons and through aggregate data, which is disseminated to all surgeons, hospitals and Departments of Health.

Qualified privilege


The Qualified Privilege (QP) declaration (PDF 2.1MB) encourages surgeon participation within the mortality audits by strictly protecting the confidentiality of information gained in the audit.

Via a blend of state and commonwealth legislation, the declaration prevents third parties from using data that becomes available as a result of the prescribed activity cannot be disclosed (in reports or publications) outside of the activity in a manner that identifies a surgeon. The confidentiality of the information received is protected accordingly and high-level data security procedures are maintained.

The QP declaration allows non-identifiable data to be used in reviewing and analysing surgical procedures, while information that may identify an individual requires the expressed approval of the individual being recognised.

With state and commonwealth authority, the declaration effectively allows surgeons to confidently participate in the mortality audits, knowing information they liberally divulge will be utilised exclusively for its designed professional development purpose and nothing else.


The Royal Australasian College of Surgeons received approval from the Minister of Health and Ageing to declare the Australian and New Zealand Audit of Surgical Mortality (ANZASM) a "quality assurance" activity under the Commonwealth QP scheme.

QP declarations encourage participation of surgeons by protecting the confidentiality of information created as part of this activity.

ANZASM is a bi-national framework of regionally based audits of surgical mortality. As of July 2007, every state in Australia has its own audit. Although regionally based, all audits are covered by an over-arching QP protection that ANZASM has obtained at the national level. In some regions, state coverage is also held.

This document explains:

  1. how the national QP legislation imposes responsibilities for legal disclosure of audit-related information on both the regional audits and their related audit staff
  2. what information the regional audit is permitted to disclose to hospitals (in relation to the Commonwealth QP scheme)

 The regional surgical mortality audits are permitted to:

  1. provide annual state and hospital reports that contain aggregated, de-identified (with respect to surgeon and patient) data that will report on the following:
  2. audit participation rates for their surgeons (exception: hospitals with consultant numbers less than two)
  3. hospital specific rates of optimal or suboptimal care of patients as compared to state and national averages
  4. information about the general quality of surgical care being undertaken at that hospital, relating to all aspects of care during a surgical admission.

The regional surgical mortality audits are not permitted to:

  1. disclose confidential information gained from audit activities to anyone other than the surgeon involved in the case or the surgeons specifically assigned to provide a peer review assessment of the case,
  2. a person who discloses information stemming from the declared activity either indirectly or directly to another person or a court of law faces a possible penalty of up to 2 years imprisonment (Section 124Y, Health Insurance Act 1973).

Important, to provide audit information to:

  1. chief executive officers, or
  2. surgical/medical/clinical directors,

at hospitals where the surgeon is practicing is not permitted by law. However, the Federal Minister of Health may authorise disclosure of information that relates to a serious offence against a law-in-force in any State or Territory. This means:

  1. identifying information can only be disclosed with the express approval of the identified individuals.
  2. the release of any such information would be unusual and should only occur after the implications of disclosure are properly considered.

Participating surgeons in the audit are permitted to identify other practitioners involved in the case.

Please note, ANZASM in partnership with Russell Kennedy lawyers compiled the QP guide (PDF 2.1MB). For further information about the QP scheme contact ANZASM.

Audit process

ACTASM is a peer-review process. Participation by consultant surgeons is a requirement of the College's Continuing Professional Development (CPD) Program.


According to the Royal Australasian College of Surgeons' Continuing Professional Development Manual 2010-12, it is "a requirement to participate in the Australian and New Zealand Audit of Surgical Mortality if a surgeon is in operative based practice, has a surgical death and an audit of surgical mortality is available in the surgeon's hospital."

  1. Participation as an assessee may be required.
  2. Participation as an assessor remains voluntary and highly recommended.

Notification of cases

The hospital notifies ACTASM of all deaths that occurred during a surgical admission.

ACTASM sends a Surgical Case Form to the treating surgeon linked to the case. The treating surgeon or a registrar (under supervision) completes the form and returns it to ACTASM (at each stage of the process the treating surgeon has right of reply).
Note: If the case does not fit the inclusion criteria for the audit, it can be excluded at this point and the case is closed.

First line assessment

ACTASM sends de-identified information to a first-line assessor (consultant surgeon, same speciality) for anonymous peer-review.

The first line assessor reviews the case and returns their professional assessment to ACTASM. As part of the review process, the assessor will identify if there was sufficient information to make an accurate review, if there are any areas that require further review and offer feedback on the case.

If there was sufficient information and there were no areas for further review, ACTASM staff send the written feedback to the treating surgeon (at each stage of the process the treating surgeon has right of reply) and the case will be closed.

Second line assessment

If there was insufficient information or further review was requested:

  1. ACTASM project staff request the medical records.
  2. The hospital provides the medical records.
  3. ACTASM project staff send the de-identified records to a second-line assessor (consultant surgeon, same speciality).
  4. The second-line assessor reviews the Surgical Case Form and the medical records and completes a one-page report.
    Note: This is undertaken in the spirit of sympathetic enquiry and must provide sufficient details for a clear view of events.
  5. The second-line assessor returns all of the documentation to ACTASM.
  6. ACTASM will send the report and feedback directly to the treating surgeon (at each stage of the process the treating surgeon has right of reply) and the case will be closed.
    At each stage of the process the treating surgeon has right of reply

ANZCA process

The ACTASM and the Australian and New Zealand College of Anaesthetists (ANZCA) now collaborate in the collection of anaesthetic-related surgical mortality.

ACTASM  is notified by the hospital of all deaths that occurred during a surgical admission, see flowchart (PDF 55KB). 

An anaesthetist may be involved when the treating surgeon alerts the possibility of an anaesthetic component of the death.

In which case, ACTASM  will send an Anaesthetic Case Form (PDF 110KB) to the treating anaesthetist for completion.

An Anaesthetic case form is:

  1. completed by the consultant anaesthetist or registrar (under supervision);
  2. returned to ACTASM in the reply paid envelope (as soon as possible);
  3. de-identified and sent to a first-line assessor (a consultant anaesthetist; same specialty, different hospital) for anonymous peer review.

If a second-line assessment (case note review) is not requested by the first-line assessor, the original anaesthetist will be sent written feedback at this point (and the case will be closed).

If a second-line assessment (case note review) is requested by the first-line assessor (that is, the case needs further investigation OR insufficient information has been provided on the case form then these steps are followed:

  1. An appropriate second-line assessor is selected.
  2. Medical records are requested by ACTASM project staff.
  3. The second-line assessor reviews the Anaesthetic Case Form (PDF 110KB), the patient's medical records and the first-line assessor's comment, before writing a one-page report.
    Note: The review is carried out and the report written in a spirit of sympathetic enquiry.
  4. The report and relevant feedback is sent to the reporting anaesthetist. The case is then closed.
  5. At each stage of the process the reporting anaesthetist has right of reply.

Frequently asked questions

Do I have to participate in the ACT Audit of Surgical Mortality?
Your participation in ACTASM is a requirement if you are a surgeon in an operative-based practice, have a surgical death and an audit of surgical mortality is available in your hospital.

Do I have to be a first or second-line assessor?
No. All surgeons participating in the audit can volunteer to be either first- or second-line assessors. There are some point incentives to encourage participation, which will increase in amount in 2010.

Are any instructions/guidelines provided for first or second-line assessors?
Yes, a "Guideline for Assessors" is provided. This document suggests the principles to adopt for the peer review assessment and includes examples. Also provided is a first- or second-line assessment form for the assessor to complete.

Is the ACTASM process confidential?
Yes. All data is de-identified and is securely stored at the ACTASM office. ACTASM reports are covered by qualified privilege.

How will ACTASM know if a patient has died under my care?
The hospital's medical records department notify ACTASM of all surgical deaths. Alternatively, surgeons may notify ACTASM directly of a death of a patient under their care.

What if I require the medical case notes to fill out the ACTASM case record form, is there as easy way for me to retrieve them?
Yes. The medical records department of each hospital will locate medical records for you.

What do I do after completing the Surgical Case Form?
Please return the Surgical Case Form to ACTASM in the reply paid envelope provided. Contact us if you have any questions or concerns.

Who do I contact if I have any queries?
Please contact the ACTASM Project Manager.

Electronic platform - Fellows interface

ANZASM now offers an electronic submissions platform called Fellows Interface. The paper-based submission format is still current and available. The new interface allows Fellows to self-report, complete and transmit surgical case and first-line assessment forms securely online.

The Fellows Interface is an "either/or option"; you can only use the online or paper system. If you wish to change from one to the other we will have to be notified to make the necessary changes.

Those who wish to take up the online option will be sent access details, and user instructions see list of user guides below:

Fellows Interface User Guide (PDF 2.1MB)
Self-generated Notification of Death User Guide (PDF 258KB)
Third Party Delegates User Guide (PDF 190KB)
Third Party Delegation - Fellows User Guide (PDF 554KB)

When submitting information to the audit office, ensure that the study ID and patient UR number are clearly labelled on all the supporting documentation. Please contact your local audit office for further details on submitting surgical case forms online.

Reports and publications

Annual Report

ACTASM Annual Report 2017 (PDF 3.7 MB)
ACTASM Annual Report 2016 (eBook)
ACTASM Annual Report 2016
(PDF 5.1 MB)
ACTASM Annual Report 2015
(PDF 2.3MB)
ACTASM Annual Report 2014
ACTASM Annual Report 2013 (PDF 1.6MB)
ACTASM Annual Report 2012 (PDF 3.8MB)


Fellows Interface User Guide (PDF 2.1MB)


Surgical Case Record Form (PDF 257KB)
First Line Assessment Form (PDF 111KB)
Second Line Assessment Form (PDF 111KB)
Anaesthetic Case Record Form (PDF 110KB)
Data Request Form (PDF 1.1MB)

Case Note Review Booklet

Case Note Review Booklet - Dec 2017 (ebook)
Case Note Review Booklet - Dec 2017 (PDF 2.1MB)
Case Note Review Booklet - May 2015 (PDF 466KB)
Case Note Review Booklet - March 2014 (PDF 1.2MB)


Issue 3 (eNews)
Issue 2
(PDF 81KB)
Issue 1 (PDF 131KB)
Canberra Doctor Article (PDF 541KB)


AOA Joint Replacement Registry
Australasian Health & Research Data Managers Association
Australasian Society for Cardiac and Thoracic Surgeons
The Australian and New Zealand College of Anaesthetists (ANZCA)
Australian and New Zealand Intensive Care Society (ANZICS)
Clinical Registries
Department of Health, ACT, Australia
Health Issues Centre
National E-Health Transition Authority
The Royal Australasian College of Medical Administrators
National Coroners Information System

Submission for Data Request

The Australia and New Zealand Audits of Surgical Mortality (ANZASM) will consider requests for data and data extracts for special reports. ANZASM is a declared Quality Assurance Activity and is required to work within specific requirements of the declaration. ANZASM must protect the confidentiality of the information it receives, to respect the privacy and sensitivity of those to whom it relates and maintain high-level data security procedures. Only de-identified data can be released.

  • Requests for data should accompanied by a reason why the analyses are required.
  • Requests should have a clear & realistic plan.
  • Requests require approval by the audit data-request subcommittee and final endorsement by the ANZASM Steering Committee.
  • Once approved, requests will be prioritised and work will proceed according to the priority list.
  • It is expected that abstracts be progressed into manuscripts within one year.All publications prepared from this RACS data need to be approved by the Director of RAAS, Chair RAAS and Chair ANZASM. 
  • All publications from RAAS are reported to the RACS Council.

Please email the completed data request form (PDF 1.1MB) to the RAAS General Manager, for national data extraction. Alternatively contact the regional audit of mortality manager for regional data extracts.


Future events

Future events will be posted here.

Previous events

ACTASM Seminar, 14 March 2018, "To operate or not and end of life care". Download report (PDF 239KB).

Dr Amanda Walker, Essential elements of safe and high quality end of life care, watch video 
Dr Simon Robertson, Decision making in areas of uncertainty, watch video
Dr Sivakumar Gananadha, Managing the deteriorating patient in an operative setting, watch video
Dr Karen Detering, Challenges in advanced care planning in an operative setting, watch video

ACTASM Workshop, 12 August 2015, "Closing the loop". 


All general enquiries can be directed to:
ACTASM - Royal Australasian College of Surgeons
Suite 31, 2 King St
Deakin ACT 2600
Telephone: +61 2 6285 4558

Clinical Director - Dr John Tharion
Project Manager - Angie Clerc-Hawke

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