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 National Center for Patient Safety
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Safety Assessment Code (SAC) Matrix
Safety
Assessment Code Matrix |
Severity
Categories |
Probablitiy
Categories
|
SEVERITY |
| Catastrophic |
Major |
Moderate |
Minor |
 |
Frequent |
3 |
3 |
2 |
1 |
|---|
| Occasional |
3 |
2 |
1 |
1 |
| Uncommon |
3 |
2 |
1 |
1 |
| Remote |
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:
- highest risk = 3
- intermediate risk = 2
- lowest risk = 1
These ranks, or Safety Assessment Codes (SAC), can then be used for
doing comparative analysis.
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Key factors for the severity categories are:
- extent of injury
- length of stay
- level of care required for remedy
-and-
actual or estimated physical plant costs.
These categories apply to actual adverse events and potential events (close calls).
For actual adverse events, assign severity based on the patient's actual condition.
If the event is a close call, assign severity based on the most likely "worst case", systems level scenario.
| Catastrophic | Major |
Patients with Actual or Potential:
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
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.
Visitors and Staff
Death; or
Hospitalization of 3 or more (includes outpatients)
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Patients with Actual or Potential:
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 of more than 3 patients
- Increased level of care for more than 3 patients
Visitors
More than 3 visitors requiring evaluation and treatment
Staff
More than 3 lost time or restricted duty injuries or illnesses
Equipment or facility
Damage more than $100,000
|
| Moderate | Minor |
Patients with Actual or Potential:
Increased length of stay for up to three patients; or
Increased level of care for up to three patients.
Visitors
Evaluation and treatment for up to three visitors
Staff
Less than three lost time or restricted duty injuries
or illnesses
Equipment or facility
Damage more than $10,000 but less than $100,000
|
Patients with Actual or Potential:
No increased length of stay or increased level of care
Visitors
Evaluated and no treatment required or refused
treatment
Staff
No lost time or restricted duty injuries or illnesses
Equipment or facility
Damage less than $10,000
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In order to assign a probability rating for an adverse event or close call,
it is ideal to know how often it occurs at your facility. Sometimes the data
will be easily available because it is routinely tracked. 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.
- Frequent - Likely to occur immediately or within a short period of time (may happen
several times in one year).
- Occasional - Probably will occur in time (may happen several times in 1 to 2 years).
- Uncommon - Possible to occur in time (may happen sometime in 2 to 5 years).
- Remote - Unlikely to occur (may happen sometime in 5 to 30 years).
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