Mental health and addiction severity assessment code (SAC) examples 2024

A colour version of this information, including table format, is available to download at the bottom of this page.

The examples below are for guidance only; they are not intended to be prescriptive or exclude other events from review. The final SAC rating can be changed following review based on the experience of harm for the consumer, not based on the number or type of learning opportunities developed. The viewpoints and experiences of consumers and whānau must be incorporated into the provisional and final SAC ratings. 

Psychological, cultural and spiritual harm 

Psychological, cultural and spiritual harm is dependent on the values and experiences of individual consumers, which makes identifying specific examples difficult. When rating an event, engage with the consumer and whānau to identify their perspective and ability to function as a result. For example, consider the psychological effect when consent isn’t obtained before an examination or procedure, not offering the opportunity for whānau support in the room during a procedure or care providers not being supportive of tino rangatiratanga, and dismissing or undermining consumer wishes. 

All documents are available in the National Adverse Events Reporting Policy.

SAC 1 – Death or harm causing severe loss of function and/or requiring life-saving intervention

• Not related to natural course of illness or treatment
• Differs from the immediate expected outcome of care
• Can be physical, psychological, cultural or spiritual

Includes:

• Suspected suicide by any consumer receiving care, treatment and services in an inpatient or monitored community mental health and addiction residential setting (eg, respite) or within 72 hours of discharge (includes approved and unapproved leave status)
• Suspected suicide by a consumer within 72 hours of attending the emergency department for a mental health and addiction-related complaint
• Suspected homicide by a current mental health and addiction consumer
• Unexpected death of a consumer due to long-term side effects of medication when in an inpatient or monitored community mental health and addiction residential setting (eg, cardiovascular disease secondary to metabolic syndrome in a consumer aged less than 50 years)
• Delayed recognition of a consumer’s deterioration resulting in death or the need for immediate life-saving resuscitation while in an inpatient or monitored community mental health or addiction residential setting (eg, cardiomyopathy, myocarditis or toxic megacolon while taking clozapine)
• Medication or treatment plan error resulting in death or the need for immediate life-saving intervention
• Death of a person missing from a mental health and addictions inpatient unit
• Fall in an inpatient setting directly resulting in life-saving intervention or death

SAC 2 – Major; harm causing major loss of function and/or requiring significant intervention

• Not related to natural course of illness or treatment
• Differs from the immediate expected outcome of care
• Can be physical, psychological, cultural or spiritual

Includes:

• Suspected suicide[1] or serious self-harm in the community by a mental health and addiction consumer within 14 days of discharge from any mental health and addiction care provider
• Serious self-harm by any consumer receiving care, treatment and services in an inpatient or monitored community mental health and addiction residential setting or within 72 hours of discharge, including from an emergency department, for consumers presenting with a mental health and addiction-related complaint and during approved and unapproved leave status
• Delayed recognition of long-term side effects of medication in an inpatient or monitored residential community mental health and addiction setting (eg, cardiovascular disease secondary to metabolic syndrome in a consumer aged less than 50 years, lithium toxicity requiring inpatient care, toxic megacolon while taking clozapine)
• Delayed recognition of a consumers’ medical deterioration requiring higher-acuity care and significant intervention while in an inpatient mental health and addiction setting
• Delayed recognition of consumer deterioration in a monitored community mental health and addiction residential setting resulting in unplanned transfer to hospital for higher-acuity care
• Medication or treatment plan error resulting in significant intervention and/or transfer to intensive or high-dependency medical care (eg, requiring dialysis, anaphylaxis from known medication allergy)
• Serious harm directly resulting from a clinical intervention (eg, collapse or fracture during restraint)
• Serious assault by a consumer in an inpatient or residential community setting causing harm (physical, psychological, spiritual or cultural) to another person (assaults on staff will also be reported through the health and safety process)
• Serious harm requiring significant intervention for a missing person from a mental health and addictions inpatient unit
• Fall in an inpatient setting resulting in fracture of major bone (ie, vertebrae, skull, jaw, neck of femur, femur, tibia, fibula, humerus, radius, ulna, pelvis), head injury or a laceration requiring significant intervention (eg, skin graft)
• Breach of privacy resulting in harm to consumer (SAC rating depends on the harm that occurs for the consumer)

SAC 3 – Moderate; harm causing short-term loss of function and/or requiring moderate additional intervention

• Not related to natural course of illness or treatment
• Differs from the immediate expected outcome of care
• Can be physical, psychological, cultural or spiritual

Includes:

• Delayed referral, follow-up, diagnosis or treatment resulting in the need for moderate additional intervention (SAC rating depends on actual harm to the consumer)
• Near-miss suicide attempt by a current mental health or addiction consumer using high-lethality method
• Medication or treatment plan error requiring minimal additional intervention (eg, transfer to a medical ward inpatient setting, higher level of mental health care, increased length of stay more than 1 week)
• Missing consumer admitted under the Mental Health (Compulsory Assessment and Treatment) Act 1992, with a risk of serious harm to self or others
• Fall in a continuous care setting resulting in minor fracture, dislocation of a joint, dental injuries or laceration
• Breach of privacy resulting in harm to consumer (SAC rating depends on the harm that occurs for the consumer)

SAC 4 – Minor; harm causing no loss of function and requiring little or no intervention (includes near misses)

• Extra investigation or observation
• Review by another clinician
• Minor treatment
• Not related to natural course of illness or treatment
• Differs from the immediate expected outcome of care
• Can be physical, psychological, cultural or spiritual

Includes:

• Near-miss suicide attempt where no harm occurs
• Medication or treatment error with no resulting harm or where minor additional monitoring is required
• Breaking of confidentiality involving disclosure of violence, resulting in increased risk to the consumer and/or their whānau
• Missing consumer from a hospital inpatient setting that poses a serious risk of harm to self or others
• Fall in a continuous care setting resulting in soft tissue injury, contusion or no injury
• Breach of privacy resulting in harm to consumer (SAC rating depends on the harm that occurs for the consumer)

Content updated May 2024.

Endnote

1. Suspected suicide in a community setting is classified as a SAC 2 because it does not occur in a continuous care setting.