Table 2

Incident coding guide

Incident	Description
A. Clinical	Events related to the delivery of care.
Safety	An event placing the patient at immediate or delayed risk of harm.
1. Drug prescription (generally applies to providers)	Selection of wrong drug or treatment regimen.
a. Change in order or new order not communicated	Change in order or new order not communicated.
b. Wrong regimen, drug, drug dose ordered or wrong patient	Wrong treatment is ordered including for wrong patient.
c. Ordered regimen or drug contraindicated	Ordered regimen or drug contraindicated because of risk, etc.
d. Dose adjustment not ordered	Dose adjustment not ordered.
e. Delays	Includes delays related to signing orders, etc.
f. Other	Other prescription-related issues.
2. Pharmacy preparation (generally applies to pharmacy staff)	Pharmacy error in preparation, labelling (incorrect or damaged) or dispensing; incompatible medication; contraindicated medication.
a. Drug preparation, labelling or release	Errors related to drug preparation including right drug, dose, concentration, patient, etc.
b. Prepared drug is incompatible or contraindicated	Incompatible or contraindicated medication is prepared.
c. Delays	Includes delays directly related to pharmacy.
d. Other	Other pharmacy preparation-related issues.
3. Medication administration and management (generally applies to infusion staff)	Errors in administering medication: dosage, strength, day, date, frequency. Includes recording or using wrong weight or height.
a. Activation before assessment	Release of chemotherapy orders to pharmacy before patient assessment.
b. Administration error	Administration error—wrong patient, drug, dose, route, schedule. Includes omitted doses or extra doses. Includes near-misses.
c. Height and/or weight	Misentered height or weight, use of wrong date, etc.
d. Laboratories	Failure to adjust treatment based on laboratory data.
e. Intravenous catheter management	Improper use of peripheral or central intravenous catheter. Includes catheter malfunction or malposition and extravasation.
f. Delays	Delays related to medication administration.
g. Other	Other medication administration/management issues.
4. Adverse drug reaction	Noxious and unintended response to a drug.
a. Potentially avoidable reaction	History not available or not considered or interaction not considered.
b. Other	Includes non-preventable adverse drug reactions.
5. Equipment or product issue	Improper equipment design or function or lack of availability. Includes issues related to blood bank.
6. Procedure	Unnecessary procedure or complication of a procedure.
7. Anaesthesia, sedation complication	Complication of anaesthesia or sedation.
8. Lab error or consequential delay	Result issue (wrong patient, incorrect result, delayed report, lost specimen, etc.).
9. Imaging error or consequential delay	Reporting error (wrong patient, incorrect result, delayed report, etc.).
10. Infection, exposure, contamination	Preventable patient or staff exposures.
Quality/knowledge management/skills	A clinical incident related to patient management.
11. Evaluation and assessment (generally applies to providers)	Incomplete assessment prior to treatment decision.
a. History, physical examination	Incomplete history, physical examination.
b. Review of relevant data	Incomplete review of relevant data including laboratory, imaging, pathology, outside information.
c. Evaluation	Incomplete, faulty or untimely evaluation.
12. Therapeutic decision making (generally applies to providers)	Failure to provide the most suitable treatment for an individual patient in a timely manner.
a. Decision making	Non-optimal or non-evidence-based decision.
b. Follow-up	Failure to arrange appropriate, timely, short-term or long-term follow-up care.
13. Evaluation or therapeutic decision making, other (generally applies to providers)	Includes other events related to evaluating and/or treating patients, including delays.
14. Staff knowledge, skills or action (can apply to any staff member)	Issues related to staff knowledge, skills or action including those that result in delays. Includes administrative errors (eg, wrong patient identifier).
B. Relational	Events related to interpersonal issues.
15. Documentation error	Incomplete, inaccurate or untimely record keeping.
16. Communication	Communication breakdown: inadequate, delayed or absent communication—generally between two parties (limited to isolated communication issues, and therefore distinct from coordination of care, see below).
17. Coordination of care	Failure to coordinate complex care across clinical staff, services, sites. Larger than communication failure. Uncoordinated or untimely service including failure to establish follow-up appointments, tests or treatments. Includes failure to complete expected service. Includes delays.
18. Other relational issues	For example, contacting the wrong patient or staff to schedule an appointment.
19. Unprofessional behaviour	Inadequate attention to patient needs (cultural, linguistic, etc), staff attitude (rudeness disrespect, insensitivity, improper behaviour); lack of respect for patient needs and preferences including those related to race, ethnicity, gender, language, etc. Includes unprofessional behaviour between staff members.
20. Patient factors	Angry or aggressive patient or caregiver; unrealistic expectations or demands, especially time-related.
C. Institutional/Management	Events related to
21. Waste or inefficiency (applies to all phases of care and staff)	Any process or event that leads to wastage of resources including staff time, equipment and medications.
22. Patient rights, equity, discrimination	Consent/Coercion; confidentiality; discrimination, abuse; failure to provide privacy. Breech of protected health information.
23. Policies, procedures (applies to all phases of care and staff)	Problem with policies or procedures. For this event, procedure refers to hospital policies and procedures rather than a clinical procedure.
a. Design issue	Policy or procedure incorrect, confusing, contradictory, non-existent or not readily available.
b. Failure to adhere	Failure to adhere to known and available policy or standard procedure.
24. Protocols and guidelines	Failure to follow existing standard of care or research protocols or clinical guidelines.
c. Design issue	Protocol or guideline incorrect, confusing, contradictory, not readily available or non-existent.
d. Failure to adhere	Failure to adhere to known and available protocol or guideline.
25. Facilities and environment	Unsafe conditions including inadequate staffing or resources to support care and unsafe environment.
D. Event category not otherwise specified	Other event category (please specify why no other category was appropriate including insufficient information).

*Contraindication. The prescription, preparation and/or administration of a medication that should not be given to an individual patient because of existing knowledge that predicts for an untoward reaction or because of concern for a negative interaction between it and another medication.
†Extravasation. Leakage of a parenteral medication into surrounding soft tissue due to malposition or malfunction of an intravenous catheter that can result in injury.