SAC Matrix Severity Definitions

Definitions and examples of how to grade incident severity

C
L
I
N
I
C
A
L
 Serious Major Moderate Minor Minimum
Patients with Death unrelated to the natural course of the illness and differing from the immediate expected outcome of the patient management, including:
  • Patient absconded from full-time medical care without obtaining consent to leave the hospital, resulting in death (suicide or murder) or major permanent loss of function.
  • Perinatal death of infanting with a birthweight ≥ 2,500gm unrelated to congenital causes.
  • Violence, murder, or other criminal activity causing dealth or major permanent loss of function to a patient
  • Patient fall resulting in death or major permanent loss of function as a direct result of injury after the fall.
  • Fire caused by medical equipment supplied by the equipment company to allow the patient to have oxygen therapy at home, which resulted in in major patient injury or death.
  • Outpatient surgery at which cardiac arrest occurred, resulting in death or permanent injury to the patient.
or
any of the following Sentinel Events:
  • Procedures involving the wrong patient or body part
  • Suicide
  • Retained instruments
  • Unintended material requiring surgical removal
  • Intravascular gas embolism resulting in death or neurological damage
  • Hemolytic blood transfusion
  • Medication error leading to death
  • Maternal death or serious morbidity associated with labor or delivery
  • Infant abduction or discharge to wrong family
  • Requires notification under existing legislative reporting requirements
 Patients with Major permanent loss of function (sensory, motor, physiologic or psychologic) unrelated to the natural course of the illness and differing from the expected outcome of patient management

or any of the following:
  • Disfigurement as a result of the incident
  • Absconded involuntary mental health patient
  • Threatened or actual physical or verbal assault of patient or staff requiring intervention
Patients with Permanent reduction in bodily functioning (sensory, motor, physiologic, or psychologic) unrelated to the natural course of the illness and differing from the expected outcome of patient management

or any of the following:
  • Increased length of stay as a result of the incident
  • Surgical intervention required as a result of the incident
 Patients requiring increased level of care including:
  • Review and evaluation
  • Additional investigations
  • Referral to another clinician
 Patients with No increased level of care or length of stay.
This group can be subdivided so that patients with No harm can be identified separately .
C
O
R
P
O
R
A
T
E 		Serious Major Moderate Minor Minimum
Staff: Permanent injury to staff member, hospitalization of 2 staff, or lost time or restricted duty or illness for 3 or more staff or pending or actual WorkCover prosecution Staff: Medical expenses, lost time or restricted duties or injury / illness for 2 or more staff Staff: First aid treatment only with not lost time or restricted duties Staff: First aid treatment only with not lost time or restricted duties Staff: No injury or review required
Visitors: Death of visitor or hospitalization of 3 or more visitors Visitors: Hospitalization of up to 2 visitors related to the incident / injury or pending or actual WorkCover prosecution Visitors: Medical expenses incurred or treatment up to 2 visitors not requiring hospitalization Visitors: Evaluation and treatment with no expenses Visitors: No treatment required or refused treatment
Services: Complete loss of service or output Services: Major loss of agency / service to users, including cancellation of booked surgery more than twice Services: Disruption to users due to agency problems Services: Reduced efficiency or disruption to agency working Services: No loss of service
Financial: loss of assets replacement value due to damage, fire etc > $1M or loss of cash / investments / assets due to fraud, overpayment or theft >$100K Financial: loss of assets replacement value due to damage, fire etc $100K-$1M or loss of cash / investments / assets due to fraud, overpayment or theft $10K-$100K Financial: loss of assets replacement value due to damage, fire etc $50K to $100K or loss of cash / investments / assets due to fraud, overpayment or theft to $10K Financial: loss of assets replacement value due to damage, fire etc to $50K Financial: No financial loss
Environmental: Toxic release off-site with detrimental effect. Fire requiring evacuation Environmental: Off-site release with no detrimental effects or fire that grows larger than an incipient stage Environmental: Off-site release contained with outside assistance or fire incipient stage or less Environmental: Off-site release contained without outside assistance Environmental: Nuisance releases
CLINICAL

Serious

Patients with Death unrelated to the natural course of the illness and differing from the immediate expected outcome of the patient management, including:

  • Patient absconded from full-time medical care without obtaining consent to leave the hospital, resulting in death (suicide or murder) or major permanent loss of function.
  • Perinatal death of infanting with a birthweight ≥ 2,500gm unrelated to congenital causes.
  • Violence, murder, or other criminal activity causing dealth or major permanent loss of function to a patient
  • Patient fall resulting in death or major permanent loss of function as a direct result of injury after the fall.
  • Fire caused by medical equipment supplied by the equipment company to allow the patient to have oxygen therapy at home, which resulted in in major patient injury or death.
  • Outpatient surgery at which cardiac arrest occurred, resulting in death or permanent injury to the patient.

or
any of the following Sentinel Events:

  • Procedures involving the wrong patient or body part
  • Suicide
  • Retained instruments
  • Unintended material requiring surgical removal
  • Intravascular gas embolism resulting in death or neurological damage
  • Hemolytic blood transfusion
  • Medication error leading to death
  • Maternal death or serious morbidity associated with labor or delivery
  • Infant abduction or discharge to wrong family
  • Requires notification under existing legislative reporting requirements

Major

Patients with Major permanent loss of function (sensory, motor, physiologic or psychologic) unrelated to the natural course of the illness and differing from the expected outcome of patient management

or any of the following:

  • Disfigurement as a result of the incident
  • Absconded involuntary mental health patient
  • Threatened or actual physical or verbal assault of patient or staff requiring intervention

Moderate

Patients with Permanent reduction in bodily functioning (sensory, motor, physiologic, or psychologic) unrelated to the natural course of the illness and differing from the expected outcome of patient management

or any of the following:

  • Increased length of stay as a result of the incident
  • Surgical intervention required as a result of the incident

Minor

Patients requiring increased level of care including:

  • Review and evaluation
  • Additional investigations
  • Referral to another clinician

Minimum

Patients with No increased level of care or length of stay.
This group can be subdivided so that patients with No harm can be identified separately .

CORPORATE

Serious

Staff: Permanent injury to staff member, hospitalization of 2 staff, or lost time or restricted duty or illness for 3 or more staff or pending or actual WorkCover prosecution

Visitors: Death of visitor or hospitalization of 3 or more visitors

Services: Complete loss of service or output

Financial: loss of assets replacement value due to damage, fire etc > $1M or loss of cash / investments / assets due to fraud, overpayment or theft >$100K

Environmental: Toxic release off-site with detrimental effect. Fire requiring evacuation

Major

Staff: Medical expenses, lost time or restricted duties or injury / illness for 2 or more staff

Visitors: Hospitalization of up to 2 visitors related to the incident / injury or pending or actual WorkCover prosecution

Services: Major loss of agency / service to users, including cancellation of booked surgery more than twice

Financial: loss of assets replacement value due to damage, fire etc $100K-$1M or loss of cash / investments / assets due to fraud, overpayment or theft $10K-$100K

Environmental: Off-site release with no detrimental effects or fire that grows larger than an incipient stage

Moderate

Staff: First aid treatment only with not lost time or restricted duties

Visitors: Medical expenses incurred or treatment up to 2 visitors not requiring hospitalization

Services: Disruption to users due to agency problems

Financial: loss of assets replacement value due to damage, fire etc $50K to $100K or loss of cash / investments / assets due to fraud, overpayment or theft to $10K

Environmental: Off-site release contained with outside assistance or fire incipient stage or less

Minor

Staff: First aid treatment only with not lost time or restricted duties

Visitors: Evaluation and treatment with no expenses

Services: Reduced efficiency or disruption to agency working

Financial: loss of assets replacement value due to damage, fire etc to $50K

Environmental: Off-site release contained without outside assistance

Minimum

Staff: No injury or review required

Visitors: No treatment required or refused treatment

Services: No loss of service

Financial: No financial loss

Environmental: Nuisance releases