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VA National Center for Patient Safety

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Safety Assessment Code (SAC) Matrix

How the SAC Matrix Works

SEVERITY
CatastrophicMajorModerateMinor
PROBABILITY
Frequent
3
2
1
Occasional
3
2
1
Uncommon
3
1
Remote
3
1

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.

CatastrophicMajor
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). This includes outcomes that are 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. Any of the adverse events defined by the Joint Commission as reviewable "Sentinel Events" should also be considered in this category (see App. A, subpar. 1b).
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) or any of the following:
  1. Disfigurement
  2. Surgical intervention required
  3. Increased length of stay for three or more patients
  4. Increased level of care for three or more patients

 

ModerateMinor
Patients with Actual or Potential:
Increased length of stay or increased level of care for one or two patients
Patients with Actual or Potential:
No injury, nor increased length of stay nor increased level of care

Probability Categories

 

Like the severity categories, the probability categories 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 how often it occurs at your facility. Sometimes the data will be easily available because they are routinely tracked (e.g., falls with injury, Adverse Drug Events (ADEs), etc.). Sometimes, getting a feel for the probability of events that 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. Like the severity categories, the probability categories apply to actual adverse events and close calls:

  • 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).