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Determining the Probability and Severity of Harm

The probability of the failure and the severity of the consequences, if the failure does occur, can be estimated. This estimate should then prompt the laboratory team to determine what risks need to be mitigated and what needs to be done to mitigate the risk to prevent negative patient outcomes. The Safety Assessment Code (SAC) is a useful tool to help with this evaluation. The SAC Matrix is provided by the VA National Center for Patient Safety and is available at: http://www.patientsafety.va.gov/professionals/publications/matrix.asp. Accessed December 5, 2014.

The table on this page is based on the VA's SAC matrix. We have added the colors, using a stoplight color scheme. In this table, the frequency and level of risk determine the color to be applied to the steps on the process map for easy, swift visualization of areas for focused action. We have provided definitions of terms used on this table. However, your laboratory team may decide to use different terms on the risk matrix and define those terms differently. This table serves only as an example.
Definitions of severity terms
  • Catastrophic-- Failure that could lead to patient death or permanent loss of function not related to the natural course of the patient's illness or underlying condition.
  • Major-- Permanent lessening of bodily functioning not related to the natural course of the patient's illness or underlying condition.
  • Moderate-- Increased length of patient hospitalization or increased level of care.
  • Minor-- No injury, increased length of hospitalization, or increased level of care.
Definitions of probability terms
  • 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).