On January 24, 1998 at 6:30 a.m. the nursing staff was providing the patient with routine a.m. care. This consisted of showering the patient in the shower room on the ward. The patient was seated in a chair being washed when he slid off the chair and hit his face, hip, and shoulder. The patient was examined by the doctor at 7:55 a.m. and transferred to our Acute Evaluation Unit (AEU) for further evaluation. The AEU physician ordered x-rays. No fractures noted. The patient was returned to the ward where neuro checks were initiated as per policy and reported as normal.

Severity Determination

The first step in assigning the SAC score is determining the severity of the event. We can see from the report that no injury was reported after evaluation by x-ray and clinical evaluation on the ward. Therefore, the actual severity would be rated as minor. However, when one considers the potential for injury, the evaluator could reasonably assess it as potentially catastrophic.

Therefore, while the actual severity would be rated as minor, the potential severity would be considered to be catastrophic. In general, the severity score assigned should be whichever one is the most severe when comparing the actual versus the potential/risk thereof (close call) assessment. In this way, the most conservative course will be selected which will enhance/maximize the potential to prevent future events of this nature. For this phase of the program, SAC scoring on potential events is not mandated--but highly encouraged.

Severity Score – Actual--Minor/Potential--Catastrophic

Probability Determination

The probability determination should be made based on the situation, actual versus the potential/risk thereof assessment, which resulted in the most severe severity assessment. The evaluator should base the probability assessment on their own experience at their facility. This, in most cases, will be the most subjective portion of the SAC score determination. It should be noted that the SAC Matrix that is used has been constructed in such a way that is minimizes the impact of this subjectivity. It must be remembered that the entire purpose of the SAC score process is to provide a framework within which to prioritize future actions and that a higher rating can be assigned if the facility feels that there are particular circumstances warrant more in depth follow-up.

Based on the experience of the evaluator, the probability of a catastrophic (using the SAC definition) outcome in a patient of this type whose head struck a hard object as the result of a fall would be medium. Wanting to be conservative, the medium assessment would be selected.

Using the SAC matrix one need only locate the severity rating and then follow down the column until reaching the row containing the probability score. In this case this would yield a "3" for a potential or a "1" for actual (near miss). Please notice that even if the probability of the event had been rated as low, the "potential" SAC score still would have been determined to be a "3" and an RCA would have been required. However, since this is classified as an "actual 1", it qualifies for an aggregated review.

Yesterday at the XX medical center, the XYZ monitor did not trigger an alarm in the SICU. The problem was observed by the nurses while they cared for a DNR patient who developed cardiac arrhythmias but the monitor failed to trigger the alarm. Since the patient had a DNR order he was not resuscitated.

Severity Determination

The first step in assigning the SAC score is determining the severity of the event. We can see from the report that the actual outcome of this event was the death of the patient. While this would definitely be thought of as a catastrophic event there are other factors to be considered.

Since the patient was classified as a DNR and the nurses who were caring for the patient witnessed the cardiac arrhythmias, the patients death was not the result of the failure of the alarm to annunciate the cardiac abnormalities. Instead, there was an appropriate decision made not to resuscitate based on the DNR order. This then would mean that the actual outcome would be considered to be a result of the natural course of the patient’s disease. As such, the severity code based on the actual outcome would be N/A and the case would not receive any further consideration if we were to stop here.

However, such an action does not take into account the potential/risk thereof (close call) assessment and does not make common sense. It was purely serendipitous that the patient was a DNR. Had this not been the case the death would not have been placed in the natural course of the disease category. It was probably also serendipitous that the cardiac arrhythmias were witnessed. This would mean that had this happened in a patient that was not in DNR status that a catastrophic event may reasonably be construed to have occurred. For these reasons the severity for this event would be determined to be catastrophic from a potential perspective. When evaluating these incidents, you must use good common judgement to determine if the scoring should be based on the actual event or the potential for a catastrophic event to occur. In this way, the most conservative course will be selected which will enhance maximize the potential to prevent future events of this nature.

Probability Determination

The probability determination should be made based on the situation, actual versus the potential/risk thereof assessment, which resulted in the most severe severity assessment. The evaluator should base the probability assessment on their own experience at their facility. This, in most cases, will be the most subjective portion of the SAC score determination. It must be remembered that the entire purpose of the SAC score process is to provide a framework within which to prioritize future actions and that a higher rating can be assigned if the facility feels that there are particular circumstances warrant more in depth follow-up.

The probability determination would rely on the experience of the evaluator. For the purposes of this illustration we will assume that the probability is thought to be low.

Using the SAC matrix one need only locate the severity rating and then follow down the column until reaching the row containing the probability score. In this case this would yield a ‘"3". Please notice that even if the probability of the event had been rated as remote, the SAC score still would have been determined to be a "3".

SAC Score - Potential--3/Actual--1

This is a 77 year old patient that was admitted on 1/16/98 and has had a complicated and complex course since his surgery for an open cholecystectomy on 1/27/98. On 2/25/98, a volunteer assisting with feeding the patient lunch came in and noted tourniquet had been left on his left arm above the wrist. Tourniquet was immediately removed; hand was deep purple. Patient is minimally responsive and would not have been able to notify nursing staff of tourniquet.

On subsequent examinations, the patient’s arm and hand returned to normal appearance – hand warm and dry, no discoloration noted; good capillary refill.

Severity Determination

The first step in assigning the SAC score is determining the severity of the event. We can see from the report that the actual outcome of this event was minor.

However, when one considers the potential for injury, the evaluator could reasonably assess the severity as potentially moderate. This is true because had the volunteer not discovered the tourniquet on this patient, who was unable to remove it themselves or call for assistance, the result could have been neurovascular compromise that may have required additional care with possible temporary lessening of function. One could also argue that the tourniquet, had it been applied tightly enough, could have resulted in the loss of the limb in some patients. This determination would have to be made by the evaluator. For the purposes of this case, it was felt that a tourniquet applied for the purpose of phlebotomy would, by definition, have to be a venous tourniquet and not an arterial tourniquet otherwise it would not serve its intended function. Therefore, it was felt that the catastrophic severity classification would be inappropriate in this case.

Therefore, while the actual severity would be rated as minor, the potential severity would be considered to be moderate. In general, the severity score assigned should be whichever one is the most severe when comparing the actual versus the potential/risk thereof (close call) assessment. In this way, the most conservative course will be selected which will enhance maximize the potential to prevent future events of this nature.

Probability Determination

The probability determination should be made based on the situation, actual versus the potential/risk thereof assessment, which resulted in the most severe severity assessment. It must be remembered that the entire purpose of the SAC score process is to provide a framework within which to prioritize future actions and that a higher rating can be assigned if the facility feels that there are particular circumstances warrant more in depth follow-up.

The probability that a phlebotomist would inadvertently leave a tourniquet on a patient was thought to be frequent, that is likely to occur several times in a year or more.

Using the SAC matrix one need only locate the severity rating and then follow down the column until reaching the row containing the probability score. In this case this would yield a ‘"2" for potential or "1" for actual.