...

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