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The following examples from each harm category demonstrate how this categorization is applied and when an event reaches a patient.
Harm Category | Examples |
|---|---|
Did not reach patient | |
A - Unsafe condition | In passing a shelf of medications, a pharmacist notices similarity between two medication names and thinks, “Someone could be confused; we should change this.” |
B - Near miss | A pharmacist reaches for a medication but incorrectly retrieves a similarly named medication right next to it. The pharmacist notices immediately, replaces the incorrect bottle, and selects the correct one. |
Did reach patient, did not harm patient | |
C - No harm, no change in care | The patient is handed incorrect medication and says to the nurse, “These aren’t my pills.” |
D - No harm, but required extra monitoring or an intervention to preclude harm | The patient is handed a dose of incorrect medication and takes it. The nurse realizes the medication was incorrect. The patient spends extra time in the hospital to make sure there are no ill effects. |
Did reach patient, resulted in harm | |
E - Temporary harm, no significant intervention | The patient is administered incorrect medication and experiences nausea and vomiting. The patient receives extra monitoring, but their hospital stay is not extended. |
F - Temporary harm, significant intervention needed | The patient is administered incorrect medication and experiences nausea and vomiting. A rescue medication is administered. |
G - Permanent harm | The patient is administered incorrect medication and experiences a seizure. The patient suffers permanent brain damage as a result. |
H - Required an intervention necessary to sustain life | The patient is administered incorrect medication and goes into cardiac arrest. The patient receives CPR and is defibrillated. |
I - Death | The patient is administered incorrect medication which ultimately results in the patient’s death. |
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