National safety priorities in mental health: a national plan for reducing harm

Appendix 7 - Examples of risk matrices

Page last updated: October 2005

Example 1. Open disclosure standard – appendix D

Example of matrix for initial assessment of level of response

The 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 response

This 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 - high
Consequence:
  • 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)
Action:
  • Immediately notify individual responsible for clinical risk management
  • Disclosure by senior medical practitioner or alternate with support where indicated
Level of response - low
Consequence:
  • No permanent Injury nor increased level of care required
Action:
  • Local management, incident report.
  • Disclosure by senior health care professional

Example of incident grading matrix

Table 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

LevelDescriptorDescription
1Insignificant No injuries, low financial loss
2MinorFirst aid treatment, on-site release immediately contained, medium financial loss
3Moderate Medical treatment required, on-site release contained with outside assistance, high financial loss
4MajorExtensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss
5CatastrophicDeath, 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

LevelDescriptorDescription
AAlmost certainIs expected to occur in most circumstances
BLikelyWill probably occur in most circumstances
CPossibleMight occur at some time
DUnlikely Could occur at some time
ERare 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

LikelihoodConsequences - insignificant
1
Consequences - minor
2
Consequences - moderate
3
Consequences - major
4
Consequences - catastrophic
5
A (almost certain)
H
H
E
E
E
B (likely)
M
H
H
E
E
C (moderate)
L
M
H
E
E
D (unlikely)
L
L
M
H
E
E (rare)
L
L
M
H
H

The number of categories should reflect the needs of the study

Legend:
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

ProbabilitySeverity - catastrophicSeverity - majorSeverity - moderateSeverity - 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.

Severity Categories

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

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)
    • 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 unauthorised 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)

Major

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
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

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

Minor

Patients with Actual or Potential:
No increased length of stay or increased level or 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

Probability

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).

Source

The SAC information above is reprinted directly from the US Department of Veterans Affairs National Centre for Patient Safety (NCPS):