DOD Patient Safety Course

Safety Assessment Code Matrix

 

Severity Categories

Key factors for the severity categories are: extent of injury; length of stay; and level of care required for remedy. The four categories below apply to actual adverse events.

For close calls/adverse events, assign severity category based on the patient's actual condition. Some incidents that occur may have such an overwhelming potential for a catastrophic event that an RCA will also be necessary, but that determination will be left to the discretion of the MTF.

 

Catastrophic

Major
   
Patients with Actual: Patients with Actual:
Death or major permanent loss of function (sensory, motor,

Physiologic, or intellectual) not related to the natural course

of the patient's illness or underlying condition (i.e., acts of

commission or omission).

Suicide (inpatient or outpatient)

Rape

Hemolytic transfusion reaction

Surgery/Procedure on the wrong patient or wrong body part

Infant abduction or infant discharge to the wrong family

 Permanent lessening of bodily functioning (sensory, motor, physiologic, or intellectual) not related to the natural course of the patient's illness or underlying conditions (i.e., acts of commission or omission).

Disfigurement

Surgical intervention required

Increased length of stay or level of care of 3 days or more

 

 
   
   
Death or major permanent loss of function that is a

Direct result of injuries sustained in a fall; or associated

With an unauthorized departure from an around-the-clock treatment setting; or the result of an assault or other crime

  
   
   
   
Moderate Minor
   
Patients with Actual: Patients with Actual:
   
Increased length of stay or higher level of care for less than 3 days No increased length of stay or increased level of care
   
   
   
   

 

Probability Recurrence

Like the severity categories, the probability recurrence apply to actual adverse events and close calls.

In order to assign a probability rating for an adverse event or close call, it is ideal to know often it occurs at your facility. Sometimes, the data will be easily available because it is routinely tracked (e.g., falls with injury, medication errors, etc.). Sometimes, getting a feel for the probability of events which are not routinely tracked will mean asking for a quick or informal opinion from staff most familiar with those events. Sometimes it will have to be your best educated guess.

High – Likely to occur immediately or within a short period of time

Medium – Likely to occur several times in 1 to 2 years.

Low –May happen greater than two years.

 

How the SAC Matrix Looks

 

Severity & Probability

Catastrophic

Major

Moderate

Minor
High

3

3

2

1
Medium

3

2

1

1
Low

3

2

1

1

 

How the SAC Matrix Works

When you pair a severity category with a probability category for either an actual event or close call, you will get a ranked matrix score (3 = highest risk, 2 = intermediate risk, 1 = lowest risk). These ranks, or Safety Assessment Codes (SACs) can then be used for doing comparative analysis, and, for deciding who needs to be notified about the event.

Notes

1. All known reporters of events, regardless of SAC score (1,2, or 3), will receive appropriate and timely feedback.

2. The Risk Manager (or designee) will refer adverse events or close calls related solely to staff, visitors or equipment/facility damage to relevant facility experts or services on a timely basis, for assessment and resolution of those situations.

3. A quarterly Aggregated Root Cause Analysis must be completed for falls and medication errors. The use of aggregated analysis serves two important purposes. First, greater utility of the analysis (i.e., trends or patterns not noticeable in individual case analysis are more likely to show up as the number of cases increases). Second, it makes better use of the RCA team's time and expertise. Remember all SAC 3s require an individual RCA.

Of course, the facility may elect to perform an individual RCA rather than Aggregated Review on any adverse event or close call that they think merits that attention, regardless of the SAC score.

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*29 CFR 1960.70 requires each federal agency to notify OSHA within 8 hours of a work-related incident which results in the death of an employee or the in-patient hospitalization of 3 or more employees.

**The Safe Medical Devices Act of 1990 requires reporting of all incidents in which a medical device may have caused or contributed to the death, serious injury, or serious illness of a patient or another individual.

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