Table 2

Diabetes mellitus risk scoring sheet

Score	Effect/consequence (harm)		Frequency of failure (frequency)/patients		Safeguard detectability (detection)
1	None	No reason to expect failure to have any effect on safety, health, environment or mission.	None	1/10 000	Almost certain	Current control(s) almost certain to detect failure mode. Reliable controls are known with similar processes.
2	Very low	Minor disruption to discharge process. Repair of failure is accomplished through verbal communication with team member. Process example: Patient’s DM status is unknown.	Very low	1/5000	Very high	Very high likelihood current control(s) will detect failure mode. Example: Automatic mean of detection that prevents the process from continuing.
3	Low	Minor disruption to discharge process. Repair of failure may take 30–60 min to correct. Outcome example: Blood glucose is 150–200 mg/dL. Process example: The provider cannot find supplies immediately because supplies are in different locations.	Low	1/2000	High	High likelihood current control(s) will detect failure mode. Example: Semiautomatic mean of detection with warning that does not prevent the process from continuing (eg, a pop-up window reminder).
4	Low to moderate	Moderate disruption to discharge process. Repair of failure takes 2 hours to correct. Outcome example: Asymptomatic hyperglycaemia (blood glucose value is 200–249 mg/dL). Process example: The caregiver is not present for diabetes education session, discharge is delayed.	Low to moderate	1/1000	Moderately high	Moderately high likelihood current control(s) will detect failure mode. Example: Semiautomatic mean of detection (eg, an alarm that does not prevent the process from continuing).
5	Moderate	Moderate disruption to discharge process. Discharge is delayed for 2–4 hours because steps are not completed in a timely fashion. Outcome example: Symptomatic hyperglycaemia (blood glucose is 200–250 mg/dL). Process example: Primary team does not contact diabetes team for discharge recommendations on time. Diabetes education is delayed and happens later in day.	Moderate	1/500	Moderate	Moderate likelihood current control(s) will detect failure mode. Example: Double human inspection with a checklist or standard aid, or triple human inspection without checklist or standard aid.
6	Moderate to high	Moderate disruption to discharge process. Discharge is delayed 4–8 hours. Outcome example: Asymptomatic hypoglycaemia (blood glucose is <70 mg/dL) or asymptomatic hyperglycaemia (blood glucose value is 250–349 mg/dL). Process example: New diabetes or hyperglycaemia onset, patient needs more time with diabetes team to feel comfortable prior to discharge. Discharge is delayed.	Moderate to high	1/200	Low	Low likelihood current control(s) will detect failure mode. Example: Double human inspection with a checklist or standard aid, or triple human inspection without checklist or standard aid.
7	High	High disruption to discharge process (1 day). Outcome example: Symptomatic hypoglycaemia (blood glucose is <70 mg/dL) or symptomatic hyperglycaemia (blood glucose value is 250–349 mg/dL). Process example: Patient deemed ready for discharge and diabetes team consulted. Patient needs more time with diabetes team before leaving the hospital. Discharge is delayed to the next day.	High	1/100	Very low	Very low likelihood current control(s) will detect failure mode. Example: Informal single human inspection (inspection is not routinely part of the process).
8	Very high	Patient suffers non-permanent damage or needs acute intervention. Outcome example: Asymptomatic hypoglycaemia (blood glucose is <40 mg/dL) or asymptomatic hyperglycaemia (blood glucose is >350 mg/dL). Rejection and infection risk increased.	Very high	1/50	Remote	Remote likelihood current control(s) will detect failure mode. Example: Informal single human inspection (inspection is not routinely part of the process).
9	Hazard	Potential safety, health or environmental issue. Outcome example: Symptomatic hypoglycaemia (blood glucose is <40 mg/dL) or symptomatic hyperglycaemia (blood glucose is >350 mg/dL). Heart attack or seizure or retransplant is associated with hypoglycaemia or hyperglycaemia.	Hazard	1/20	Very remote	Very remote likelihood current control(s) will detect failure mode.
10	Hazard	Potential safety, health or environmental issue. Outcome example: Blood glucose is <40 mg/dL. Patient dies.	Hazard	1/10+	Almost impossible	No known control(s) available to detect failure mode.

DM, diabetes mellitus.