Example 1. Open disclosure standard – appendix D
Example of matrix for initial assessment of level of responseThe following table is an example of a matrix to assess the level of response to an adverse event/incident. The matrix used will vary depending on local policies.
Assessment of level of responseThis table is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Level of response - highConsequence:
- Death or major permanent loss of function not related to the natural condition of the patient
- Permanent lessening of bodily function not related to underlying condition of patient or where surgical intervention or transfer to higher level of care required (eg transfer to ICU)
- Immediately notify individual responsible for clinical risk management
- Disclosure by senior medical practitioner or alternate with support where indicated
Level of response - lowConsequence:
- No permanent Injury nor increased level of care required
- Local management, incident report.
- Disclosure by senior health care professional
Example of incident grading matrixTable 1 is an example of a matrix for grading an Incident to determine the level of investigation required. The matrix used will vary depending on the policy of the organisation.
The tables are reproduced from AS/NZS 4360 Risk management. It is strongly recommended that users of the Open Disclosure Standard consult the complete AS/NZS 4360 for the context in which this table is presented and for detailed information on its use and application.
Table 1: Qualitative measures of consequence or impact
|1||Insignificant||No injuries, low financial loss|
|2||Minor||First aid treatment, on-site release immediately contained, medium financial loss|
|3||Moderate||Medical treatment required, on-site release contained with outside assistance, high financial loss|
|4||Major||Extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss|
|5||Catastrophic||Death, toxic release off-site with detrimental effect, huge financial loss|
Measures used should reflect the needs and nature of the organisation and activity under the study.
Table 2: Qualitative measures of likelihood
|A||Almost certain||Is expected to occur in most circumstances|
|B||Likely||Will probably occur in most circumstances|
|C||Possible||Might occur at some time|
|D||Unlikely||Could occur at some time|
|E||Rare||May occur only in exceptional circumstances|
Measures used should reflect the needs and nature of the organisation and activity under study.
Table 3: Qualitative risk analysis matrix - level of risk
|Likelihood||Consequences - insignificant |
|Consequences - minor |
|Consequences - moderate |
|Consequences - major |
|Consequences - catastrophic |
|A (almost certain)|
The number of categories should reflect the needs of the study
E - extreme risk; immediate action required
H - high risk; senior management attention needed
M - moderate risk; management responsibility must be specified
L - low risk; manage by routine procedures
Source: Australian Council for Safety and Quality in Health Care (2003) Open Disclosure Standard: a National Standard for Open Communication in Public and Private Hospitals, Following an Adverse Event in Health Care, Commonwealth of Australia, July 2003. pp 37-39.
Example 2: Safety Assessment Code (SAC) Matrix
|Probability||Severity - catastrophic||Severity - major||Severity - moderate||Severity - minor|
How the SAC matrix worksWhen 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
Severity CategoriesKey factors for the severity categories are:
- extent of injury
- length of stay
- level of care required for remedy
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 (ie acts of commission or omission).
- Suicide (inpatient or outpatient)
- 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 unauthorised departure from an around-the-clock treatment setting; or the result of an assault or other crime.
Visitors and StaffDeath; or Hospitalization of 3 or more (includes outpatients)
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 (ie 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
VisitorsMore than 3 visitors requiring evaluation and treatment
StaffMore than 3 lost time or restricted duty injuries or illnesses
Equipment or facilityDamage more than $100,000
Patients with Actual or Potential:Increased length of stay for up to three patients; or Increased level of care for up to three patients.
VisitorsEvaluation and treatment for up to three visitors
StaffLess than three lost time or restricted duty injuries or illnesses
Equipment or facilityDamage more than $10,000 but less than $100,000
Patients with Actual or Potential:No increased length of stay or increased level or care.
VisitorsEvaluated and no treatment required or refused treatment
StaffNo lost time or restricted duty injuries or illnesses
Equipment or facilityDamage less than $10,000
ProbabilityIn 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).
SourceThe SAC information above is reprinted directly from the US Department of Veterans Affairs National Centre for Patient Safety (NCPS):
- NCPS website (www.patientsafety.gov) (link was correct at time of printing)
- Safety Assessment Code (SAC) Matrix page (www.patientsafety.gov/matrix.html) (link was correct at time of printing)