Description

Determination of whether or not the event reached the patient.

On-Screen Instructions

ASC, Hospital, Nursing Facility: An error of omission does reach the patient.

Pharmacy: Includes medications that make it into the patient’s possession. An error of omission does reach the patient.

Field Type

Responses

Yes
No

Guide for Use

If you chose more than one event type, please select the highest applicable level of harm.

Additional Support

What is a Close Call?

The Oregon Patient Safety Commission (OPSC) defines a “close call” or “near miss” as a situation that has the potential to cause an adverse event, or a situation that causes an adverse event but fails to reach the patient because of chance or because it is intercepted. Close calls include cases where there was the potential for an adverse event but no actual adverse event occurred (harm category A) or where the adverse event did not reach the patient (harm category B). OPSC encourages organizations to investigate close calls because they give facilities an opportunity to solve identified problems before a single patient has to experience an adverse event.

If an event reaches the patient but does not cause harm (harm category C), OPSC no longer considers the event a close call. For example, a patient with a documented penicillin allergy does not have an allergic reaction when given a single dose of penicillin; this event would not be included in OPSC’s definition of close call.

In the interest of promoting learning, OPSC encourages reporting of close calls (harm categories A and B) and no harm events (harm categories C and D) because such events have the potential to harm a patient and, depending on the situation and patient factors, such harm could be severe. OPSC encourages participants to focus on the occurrence of an adverse event instead of the resulting harm. Focusing on the harm, rather than the system, often detracts from the real goal—preventing future recurrence and, therefore, future harm for all patients.

When does an event reach the patient?

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

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.

Whether or not an adverse event reaches a patient can be complicated by questions of omission and care delay. In cases where it’s unclear, it’s important to ask, “Did this event impact the patient’s course of care?”

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	2012
End Date	n/a
Change History	n/a
Field Name	algorithm_reachpt

PSRP Knowledge Base

Did the event reach the patient?