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National Center for Patient Safety

Safety Assessment Code (SAC) Matrix



 SEVERITY
Catastrophic   Major   Moderate   Minor  
probability written vertically Frequent
16
12
8
4
Occasional
12
9
6
3
Uncommon
8
6
4
2
Remote
4
3
2
1

How to use this matrix:

  1. Determine the severity and probability of the hazard, based on the definitions included with this matrix. (Note: These definitions are the same as those used in the Root Cause Analysis Safety Assessment Code.)
  2. Look up the hazard score on the matrix.

    Catastrophic Event

    (Traditional FMEA rating of 10 - Failure could cause death or injury.)

    Major Event

    (Traditional FMEA rating of 7 - Failure causes a high degree of customer dissatisfaction.)

    Patient Outcome:
    Death or major permanent loss of function (sensory, motor, physiologic, or intellectual) suicide, rape, hemolytic transfusion reaction, surgery/procedure on the wrong body part, infant abduction or infant discharge to the wrong family

    Visitor Outcome
    Death; or Hospitalization of 3 or more

    Staff Outcome
    Death; or Hospitalization of 3 or more

    Equipment or facility:
    Damage more than $100,000

    Fire:
    Any fire that grows larger than an incipient stage

    		Patient Outcome:
    Permanent lessening of bodily functioning (sensory, motor, physiologic, or intellectual), disfigurement, surgical intervention required, increased length of stay of more than 3 patients, increased level of care for more than 3 patients

    Visitor Outcome:
    Hospitalization of 1 or 2 visitors

    Staff Outcome:
    Hospitalization of 1 or2 staff or 3 or more staff experiencing lost time or restricted-duty injuries or illnesses

    Equipment or facility:
    Damage more than $100,000

    Fire:
    Not applicable - See "Moderate" and "Catastrophic"

    Moderate Event

    (Traditional FMEA rating of 4 - Failure can be overcome with modifications to the process or product, but there is minor performance loss.)

    Minor Event

    (Traditional FMEA rating of 1 - Failure would not be noticeable to the customer and would not afffect delivery of the service or product.)
    Patient Outcome:
    Increased length of stay or increased level of care for 1 or 2 patients.

    Visitor Outcome:
    Evaluation and treatment for 1 or 2 visitors (less than hospitalization)

    Staff Outcome:
    Medical expenses, lost time, or restricted-duty injuries or illness for 1 or 2 staff.

    Equipment or facility
    Damage more than $10,000 but less than $100,000

    		Patient Outcome:
    No injury nor increased length of stay nor increased level of care

    Visitor Outcome:
    Evaluated and no treatment required or refused treatment

    Staff Outcome:
    First aid treatment only, with no lost time or restricted-duty injuries or illnesses.

    Equipment or facility:
    Damage less than $10,000 or loss of any utility without adverse patient outcome (eg, natural gas, electricity, water, communications, transport, heat/air conditioning).

    Fire:
    Not applicable - See "Moderate" and "Catastrophic."

    Probability Rating Scale

    • 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).

    Return to JQI HFMEA Article

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