Using the following gradings, please indicate the degree of harm to the patient (severity)

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Harm is defined as injury, suffering, disability or death.

The patient safety incident can have an impact on the patient at various levels, from Low right through to the Death of one or more patients. Please select the category that best describes the degree of harm suffered by the patient.


Click once on the words [display / hide category] to display additional information and examples; click a second time to hide them.

Low [display / hide category]

Any unexpected or unintended incident that required extra observation or minor treatment and caused minimal harm to one or more persons.

Examples

Perforation of the bowel during surgery,that was repaired at the time and the area was appropriately washed out. Only antibiotic treatment is required.

A patient is given someone else's medication. The medication is the same as they normally take, but at a slightly higher dose, and they need to go to bed earlier due to drowsiness.

Continuing treatment with warfarin without monitoring clotting levels, which results in prolonged clotting times, and in turn causes bruising.

An ambulance crew are called to a patient at home with chest pain. On arrival they decide to administer oxygen, and are then told the patient has had a laryngectomy. There are no laryngectomy masks on the vehicle so the crew have to attempt to oxygenate the patient using a face mask over the stoma. On arrival in A&E the patient's oxygen saturation levels have dropped from 92% to 85%.

Blood is given to the wrong patient and causes a minor rash and temporary rise in temperature.

Moderate [display / hide category]

Any unexpected or unintended incident that resulted in further treatment, possible surgical intervention, cancelling of treatment, or transfer to another area, and which caused short-term harm to one or more persons.

Examples

Perforation of the bowel during surgery was not picked up at the time. It results in septicaemia and a return to theatre for repair.

A patient is given someone else's medication. The medication is stronger than their own and they suffer prolonged drowsiness for a week. The patient needs frequent observation of their respiratory rate.

Continuing treatment with warfarin without monitoring clotting levels, which results in an overdose and bleeding problems.

An ambulance crew are conveying a patient from the ambulance to A&E on a trolley bed. The patient is left unattended for a short period and the trolley bed tips over. The patient suffers short-term loss of consciousness and needs to be admitted to hospital for observation. There is no longer-term head injury.

Wrong blood is given to a patient, resulting in temporary renal failure.

Severe [display / hide category]

Any unexpected or unintended incident that caused permanent or long-term harm to one or more persons.

Examples

Perforation of the bowel during surgery, requiring a temporary colostomy and subsequent major operations.

A patient is given someone else's medication. They have an allergic reaction to it, have a cardiac arrest and suffer brain damage as a result of receiving the medication.

Continuing treatment with warfarin without monitoring clotting levels, which results in a brain haemorrhage and brain damage.

An ambulance is called to a patient who has fallen from scaffolding. On arrival the patient is conscious but lying awkwardly, with a leg that is clearly fractured and twisted. Before carrying out a full assessment or immobilising the cervical spine, the crew reposition the patient to straighten the leg. After repositioning, the patient is unable to move any of their limbs, and later investigations identify that they have a cervical fracture and spinal cord damage. The spinal cord was, however, immobilised immediately after repositioning. The patient is left with long-term paralysis from the neck down.

Wrong blood is given to a young woman, who then develops anti-D antibodies that will affect any future pregnancy.

Death [display / hide category]

Any unexpected or unintended event that caused the death of one or more persons.

Examples

Death as a direct consequence of perforation of the bowel during surgery.

A patient is given someone else's medication. They have an allergic reaction to it, have a cardiac arrest and die as a result of receiving the medication.

Continuing treatment with warfarin without monitoring clotting levels, which results in a brain haemorrhage and death.

An ambulance responding to an emergency call on blue lights goes through red traffic lights at an intersection. A car approaching the intersection has a green light, does not see the ambulance and attempts to cross. The ambulance is unable to stop and hits the car on the driver's side. The driver of the car suffers multiple injuries and later dies in hospital.

Wrong blood is given to a patient resulting in multi-organ failure and death.