Table 2

Incident coding guide

A. ClinicalEvents related to the delivery of care.
 SafetyAn 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 communicatedChange in order or new order not communicated.
   b. Wrong regimen, drug, drug dose ordered or wrong patientWrong treatment is ordered including for wrong patient.
   c. Ordered regimen or drug contraindicatedOrdered regimen or drug contraindicated because of risk, etc.
   d. Dose adjustment not orderedDose adjustment not ordered.
   e. DelaysIncludes delays related to signing orders, etc.
   f. OtherOther 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 releaseErrors related to drug preparation including right drug, dose, concentration, patient, etc.
   b. Prepared drug is incompatible or contraindicatedIncompatible or contraindicated medication is prepared.
   c. DelaysIncludes delays directly related to pharmacy.
   d. OtherOther 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 assessmentRelease of chemotherapy orders to pharmacy before patient assessment.
   b. Administration errorAdministration error—wrong patient, drug, dose, route, schedule. Includes omitted doses or extra doses. Includes near-misses.
   c. Height and/or weightMisentered height or weight, use of wrong date, etc.
   d. LaboratoriesFailure to adjust treatment based on laboratory data.
   e. Intravenous catheter managementImproper use of peripheral or central intravenous catheter. Includes catheter malfunction or malposition and extravasation.
   f. DelaysDelays related to medication administration.
   g. OtherOther medication administration/management issues.
  4. Adverse drug reactionNoxious and unintended response to a drug.
   a. Potentially avoidable reactionHistory not available or not considered or interaction not considered.
   b. OtherIncludes non-preventable adverse drug reactions.
  5. Equipment or product issueImproper equipment design or function or lack of availability. Includes issues related to blood bank.
  6. ProcedureUnnecessary procedure or complication of a procedure.
  7. Anaesthesia, sedation complicationComplication of anaesthesia or sedation.
  8. Lab error or consequential delayResult issue (wrong patient, incorrect result, delayed report, lost specimen, etc.).
  9. Imaging error or consequential delayReporting error (wrong patient, incorrect result, delayed report, etc.).
  10. Infection, exposure, contaminationPreventable patient or staff exposures.
 Quality/knowledge management/skillsA clinical incident related to patient management.
  11. Evaluation and assessment (generally applies to providers)Incomplete assessment prior to treatment decision.
   a. History, physical examinationIncomplete history, physical examination.
   b. Review of relevant dataIncomplete review of relevant data including laboratory, imaging, pathology, outside information.
   c. EvaluationIncomplete, 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 makingNon-optimal or non-evidence-based decision.
   b. Follow-upFailure 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. RelationalEvents related to interpersonal issues.
  15. Documentation errorIncomplete, inaccurate or untimely record keeping.
  16. CommunicationCommunication 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 careFailure 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 issuesFor example, contacting the wrong patient or staff to schedule an appointment.
  19. Unprofessional behaviourInadequate 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 factorsAngry or aggressive patient or caregiver; unrealistic expectations or demands, especially time-related.
C. Institutional/ManagementEvents 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, discriminationConsent/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 issuePolicy or procedure incorrect, confusing, contradictory, non-existent or not readily available.
   b. Failure to adhereFailure to adhere to known and available policy or standard procedure.
  24. Protocols and guidelinesFailure to follow existing standard of care or research protocols or clinical guidelines.
   c. Design issueProtocol or guideline incorrect, confusing, contradictory, not readily available or non-existent.
   d. Failure to adhereFailure to adhere to known and available protocol or guideline.
  25. Facilities and environmentUnsafe conditions including inadequate staffing or resources to support care and unsafe environment.
D. Event category not otherwise specifiedOther 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.