Serious Adverse Events

This section will be helpful for CRAs who need to report a Serious Adverse Event for a subject. 

1. Begin on Home Page > Subjects menu > CRA Console
2. Select a protocol by entering the protocol number in the Select Protocol field
3. Find Subject and click on Subject "Epic MRN" hyperlink
4. Click the SAEs vertical tab
5. Create a new SAE record
   1. Click "New"
   2. Enter the following Required Fields into the "Subject SAE Update" block
      1. Event Date
         1. Date the event became serious
      2. Event End Date (Required for Oncology only)
         1. Date the event stopped being serious
      3. Reported Date
         1. Date SAE is first reported to protocol required recipient (e.g. industry sponsor/drug manufacturer, Wash U, NCI, etc.)
      4. PI Comments (Required for Oncology only)
         1. T
      5. Outcome
         1. Outcome of the event at time of SAE reporting (usually ongoing as of 24 hours)
      6. SAE Classifications (Required for Oncology only)
         1. Select choice from dropdown (e.g. Inpatient hospitalization, note: you can only select one)

1. You will need to get MD input to answer the following required fields.
2. Category, AE Detail, Grade/Severity, Unexpected, DLT, Action, Source/Attribution Box (Investigation Tx field is mandatory, other fields preferred if available)
3. Enter the following Oncology Required Fields in the "Tracking Details" block
   1. Notified FDA (date): For IITs, if applicable the date MedWatch form was submitted for the FDA
   2. Notified Regulatory (date): Same as Reported Date
   3. Team Reviewed (date): Date anyone on the research team (anyone in myIRB) found out about the SAE
4. Click the "Submit" and "Close" button
5. Attach supporting documents
6. Document Type: SAE Form
7. Upload: All completed forms and documents for the initial SAE report in PDF format
8. Submit: To complete, click "Submit". Do not click "Complete and Lock".

1. If needed, create a Follow-Up SAE record
   1. Find the SAE record associated with the one you are updating and click on its "Event No. hyperlink"
   2. Click the "Create Follow-Up" button
   3. Enter updated information for the following Required Fields:
      1. Event Date
      2. Reported Date
      3. Outcome
      4. Notified Regulatory (date) (Required for Oncology only)
   4. Make any other updates to the original SAE
   5. Click the "Submit" and "Close" button
      
   6. For Oncology studies, in the "Supporting Documents" block, click Add
      1. Upload the PI Signed SAE Report
2. To Complete SAE Record:
   1. Find the SAE record associated with the one you are updating and click on its "Event No. hyperlink"
   2. Click "Update"
   3. Enter the following Oncology Required Fields into the "Adverse Event Details" block
      
      1. Category
         1. The category option list is dependent upon the coding scheme associated with the protocol. For protocols using CTC V4, the category list corresponds to System Organ Class
      2. AE Detail
         1. The AE Detail option list is dependent upon the coding scheme associated with the protocol. For protocols using CTC V4, the category list corresponds to the System Organ Class
      3. Grade
         1. Grade is the severity of the AE. For protocols using CTC V4, grades 1 through 5 will display
      4. Unexpected
         1. An SAE is unexpected if its nature or severity is not consistent with information relevant source document(s) (e.g. investigator's brochure, consent, protocol)
   4. Click the "Add" button
   5. Click the "Submit" and "Close" button
   6. Navigate back to the SAE record associated with the one you are updating and click on its "Event No. hyperlink"
   7. Click "Update"
   8. Ensure SAE information is Complete
   9. In the "Tracking Details" block, enter the Notified Sponsor Action Date
   10. In the "Supporting Documents" block, click add and upload the PI Signed SAE Report
   11. Click the "Complete and Lock" button
   12. The Regulatory Coordinator should complete the SAE Record according to the instructions on the "Updating Regulatory Reportable Event Information" Work Instruction

*Required fields marked in red, bold font, required for all unless Oncology specifically called out

Common Terminology Criteria for Adverse Events (CTCAE):

•  Set of criteria for the standardized classification of adverse effects of drugs used in cancer therapy.
• Each oncology protocol should specify which version of the CTCAE should be utilized.
• The CTCAE version can be updated/changed in the management tab of the PC console by the regulatory coordinator as long as no SAEs have been documented.