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Description
Determination of whether or not the event reached the patient.
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The Patient Safety Reporting Program (PSRP) categorizes patient harm from adverse events using an adaptation of the widely-adopted Medication Error Index from the National Coordinating Council for Medication Error Reporting and Prevention. Categorization enables PSRP data analysis to identify trends in how and why adverse events occur.
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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For example, in the scenario for harm category C (above), if the nurse noticed the medication was incorrect before handing it to the patient and was able to immediately hand the patient the correct medication, then the event didn’t reach the patient (harm category B). However, if getting the correct medication and giving it to the patient caused an administration delay, then the event reached the patient. Although the patient never received the incorrect medication, the event “reached the patient” because the patient’s course of care was impacted.
History
Start Date | Spring 2012 |
|---|---|
End Date | n/a |
Change History | n/a |
Field Name | algorithm_reachpt |