Appendix B
OCCURRENCE CODE | INCLUDES | EXCLUDES |
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Medication Errors:
Topical, Injectables, IV, PO Treatment Medications, Contrasts, Chemotherapy 915-920 codes and Root Cause Analysis Required. |
(Permanent harm is harm that is enduring and cannot be rectified by treatment) Refer to definition manual pages 7-8 |
108-110. Any adverse drug reaction that was not the result of a medication error. |
109. A medication error occurred that resulted in a near-death event (e.g., cardiac or respiratory arrest requiring BLS or ACLS). Refer to definition manual pages 7-8 |
109. A medication error that resulted in the need for treatment, intervention, initial or prolonged hospitalization and caused temporary patient harm.
Examples: A medication error where a patient is given glucose to counteract a low blood sugar from an overdose of insulin; or a patient is given naloxone (narcan) to counteract an overdose of narcotic |
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110. A medication error occurred that resulted in a patient death.
Refer to definition manual pages 7-8 |
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Aspiration |
Refer to definition manual page 9 |
201. Patients intubated on ventilation, or with known history of chronic aspiration. |
Intravascular Catheter Related | 301. Necrosis or infection requiring repair incision and drainage (I&D), debridement, or other surgical intervention), regardless of the location for the repair (e.g., at the bedside, in a treatment room, in the OR). Refer to definition manual page 10 |
301. Any infiltration or infection treated exclusively with cold or warm packs, wound irrigation, IV change, and/or medication use (e.g., IV, PO, topical). |
Refer to definition manual page 11 |
Volume overload occurrences related to blood transfusion are reported to Blood and Tissue Resources Program only. |
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Refer to definition manual page 12 |
303. Non-intravascular catheter related pneumothoraces such as those resulting from lung biopsy, thoracentesis, permanent pacemaker insertion, etc. | |
Embolic and Related Disorders
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401. New, acute pulmonary embolism, confirmed, or suspected and treated.
Refer to definition manual page 13 |
Acute pulmonary embolism present on admission and not associated with previous hospitalization within the past 30 days. |
402. New documented DVT (deep vein thrombosis)
Refer to definition manual page 14 |
402. Superficial thrombophlebitis. New documented DVT present on admission and not associated with previous hospitalization within the past 30 days. | |
Laparoscopic | 501. All unplanned conversions to an open procedure because of an injury and/or bleeding during the laparoscopic procedure.
Refer to definition manual page 15 |
501. Diagnostic laparoscopy with a planned conversion or conversion based on a diagnosis made during the laparoscopic procedure. Conversions due to difficulty in identifying anatomy. |
Perioperative/Periprocedural Related
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600’s category |
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Refer to definition manual pages 16-18 |
601-604 Cardiac related occurrences complications) reported in the cardiac reporting systems (refer to definition manual pages 77-82).
603-604 Multiple trauma, AAA rupture known at time of surgery ESRD (End Stage Renal Disease) patients post dialysis treatment. (Include only if occurs while patient is in dialysis area.) NOTE:Consider the 911-963 codes when applicable
Birth related neonatal events reported to Perinatal Data System (page 86).
603-604 Multiple trauma, AAA rupture known at time of surgery. ESRD (End Stage Renal Disease) patients post dialysis treatment. (Include only if occurs while patient is in dialysis area.) |
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602. Any new peripheral neurological deficit (e.g., palsy, paresis) with motor weakness.
Refer to definition manual pages 16, 19, 20 |
602. Deficits due to operative or other procedure on a specific nerve (e.g., procedures involving neurofibroma, acoustic neuroma). Sensory symptoms or deficits without motor weakness (e.g., numbness or tingling, alone).
Deficits due to central neurological insults (such as hemiparesis) are submitted as a 601. Birth related neonatal events reported to Perinatal Data System (page 86). Intentional arrest during cardiopulmonary procedures. Cardiac arrest with unsuccessful resuscitation (consider code 915). |
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603. Cardiac arrest with successful resuscitation .
Refer to definition manual pages 16, 21 604. AMI (Acute Myocardial Infarction) – unrelated to a cardiac procedure. Refer to definition manual pages 16, 22 605. Death occurring after procedure See attached list (include ASA class if the procedure involves general anesthesia or conscious sedation) Refer to definition manual pages 16, 23-24 |
603-604 Multiple trauma, AAA rupture known at time of surgery.
NOTE: Consider the 911-963 codes when applicable |
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Burns/Falls |
Refer to definition manual page 25 |
701 1st degree burns. |
Refer to definition manual page 26 |
NOTE:Consider the 911-963 codes, when applicable
|
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Procedure Related
* Excludes code 808
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800’s category
Any procedural injury to liver or spleen, including injury associated with lysis of adhesions or manipulation of the organ. Refer to definition manual pages 27-31 |
801-819. Cardiac related occurrences (complications) reported in the Cardiac Reporting Systems (refer to pages 80-85 of the definition manual).
Maternal and Neonatal related occurrences reported in the Statewide Perinatal Data System (refer to pages 86-87 of the definition manual). NOTE:Consider the 911-963 codes, when applicable. Procedure related injuries which do not penetrate, perforate or enter a lumen, require only a suture(s) to serosal/muscular layers to repair, and which do not require removal of an organ. Procedure related injuries resulting from intended, direct operation on an organ or other anatomical structure based on disease process or lack of an alternative approach available to address the presenting surgical condition. Perineal lacerations from childbirth. 801-819. Cardiac related occurrences (complications) reported in the Cardiac Reporting Systems (refer to pages 80-85 of the definition manual). Maternal and Neonatal related occurrences reported in the Statewide Perinatal Data System (refer to pages 86-87 of the definition manual). NOTE:Consider the 911-963 codes, when applicable. |
803. Hemorrhage or hematoma requiring drainage, evacuation or other procedural intervention.
Refer to definition manual pages 27-28, 32-33 |
803. Vaginal packing intervention and routine blood transfusion given during or after initial procedure for procedure related blood loss. Postpartum hemorrhage requiring removal of retained Placenta only. | |
804. Anastomatic leakage requiring repair.
Refer to definition manual pages 27-28, 34 805. Wound dehiscence requiring repair. Refer to definition manual pages 27-28, 35 |
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806. Displacement, migration or breakage of an implant, device, graft, or drain, whether repaired, intentionally left in place or removed.
Refer to definition manual pages 27-28, 36 |
Patient initiated occurrences (e.g., patient removes G.T.) NOTE: If caused by hemorrhage report as code 803, if caused by post-op wound infection report as code 808. |
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807. Thrombosed distal bypass graftrequiring repair.
Refer to definition manual pages 27-28, 37 |
807. AV grafts and fistulas used for dialysis. | |
Refer to definition manual pages 27-28, 38-41. |
808. Contaminated or dirty case procedure.
Allograft occurrences (tissue transplant) report to Tissue Resources Program only (see page 75 of the definition manual). |
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Procedure Related
* Excludes code 808
Include readmissions |
819- Any unplanned operation or reoperation (RTOR) related to the primary procedure, regardless of setting of primary procedure. (If occurrence involves 801 or 803-808, enter 801 or 803-808 in the 1st occurrence code field, followed by 819 in the 2nd occurrence code field.)
Refer to definition manual pages 27-28, 42-43 |
Procedures that are commonly sequential or repeated (skin flaps, colostomy closure, 2nd look trauma, biopsy follow-up, documented planned 2nd look for ischemia after bowel resection or whenever intestinal ischemia is expected). Also lap 2nd look post oncologic procedure when post-op adjuvant therapy was given (ovarian cancer, Hodgkin’s and non-Hodgkins lymphoma). Excludes debridement, vascular cases where conservative approach tried first (thrombectomy, fem-pop bypass) but ultimately fails (BKA done as last resort). Postpartum hemorrhage requiring removal of retained Placenta only. |
Procedure Related
* Excludes code 808
Include readmissions |
851. Post partum hysterectomy
Refer to definition manual pages 27-28, 44 852. Inverted uterus Refer to definition manual pages 27-28, 45 853. Ruptured uterus Refer to definition manual pages 27-28, 46 |
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854. Circumcision requiring repair
Refer to definition manual pages 27-28, 47 |
854. Planned suture during procedure | |
Root Cause Analysis Required | 900’s category Serious events such as unexpected deaths are reportable as 900 codes even if the surgery was a CABG. |
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911. Wrong Patient, Wrong Site-Surgical Procedure Refer to definition manual pages 48-49, 52 |
Endoscopy- code as 912 |
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912. Incorrect Procedure or Treatment - Invasive
Refer to definition manual pages 48-49, 53 |
Transfusion related occurrences (report to Blood and tissue resources program only). |
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913. Unintentionally retained foreign body due to inaccurate surgical count or break in procedural technique (sponges, lap pads, instruments, guidewires from central line insertion, cut intravascular cannulas, needles, etc.)
Refer to definition manual pages 48-49, 54 |
913. Foreign bodies retained due to equipment malfunction or defective product (report under 937 or 938) or those reported under 806. | |
915-919.
Any unexpected adverse occurrence not directly related to the natural course of the patient’s illness or underlying condition resulting in:
Report Death of fetus/neonate meeting the following criteria: For live or still birth
NOTE: Include any Iatrogenic occurrence resulting in death at any gestation/weight Refer to definition manual pages 48-49, 58-59 |
915-919. Any unexpected adverse occurrence directly related to the natural course of the patient’s illness or underlying condition (e.g., terminal or severe illness present on admission).
Exclude deaths of fetus/neonate with presence of congenital anomalies incompatible with life (e.g., Anencephalus, Trisomy 13,18, Trachael or Pulmonary Atresia, Multiple life threatening Anomalies). Exclude Transfusion related death (Report to Blood and Tissue Resources Program only) See definition manual page 79. NOTE: Any cases involving malfunction of equipment resulting in death or serious injury should be reported under 938. |
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Root Cause Analysis Required | 915-919.
Any unexpected adverse occurrence not directly related to the natural course of the patient’s illness or underlying condition resulting in:
Report Death of fetus/neonate meeting the following criteria: For live or still birth
NOTE: Include any Iatrogenic occurrence resulting in death at any gestation/weight Refer to definition manual pages 48-49, 58-59 |
915-919. Any unexpected adverse occurrence directly related to the natural course of the patient’s illness or underlying condition (e.g., terminal or severe illness present on admission).
Exclude deaths of fetus/neonate with presence of congenital anomalies incompatible with life (e.g., Anencephalus, Trisomy 13,18, Trachael or Pulmonary Atresia, Multiple life threatening Anomalies). Exclude Transfusion related death (Report to Blood and Tissue Resources Program only) See definition manual page 79. NOTE: Any cases involving malfunction of equipment resulting in death or serious injury should be reported under 938. |
915-919
Any unexpected adverse occurrence not directly related to the natural course of the patient’s illness or underlying condition resulting in:
Refer to definition manual pages 48-49, 60 917. Loss of limb or organ. Refer to definition manual pages 48-49, 61 |
915-919 Any unexpected adverse occurrence directly related to the natural course of the patient’s illness or underlying condition (e.g., terminal or severe illness present on admission).
916. Events not requiring BLS/ACLS intervention. 916-919. Birth related neonatal events reported in the Statewide Perinatal System. See page 86. |
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918. Impairment of limb (limb unable to function at same level prior to occurrence) and impairment present at discharge or for at least 2 weeks after occurrence if patient is not discharged.
Refer to definition manual pages 48-49, 62 |
918. Limb functions at the same level as prior to the occurrence, impairment resolves by discharge or within two weeks if not discharged.
Excludes positioning parathesias. |
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Refer to definition manual pages 48-49, 63 |
Excludes positioning parathesias. |
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920. Errors of OMISSION/DELAY resulting in death or serious injury RELATED to the patient’s underlying condition.
Refer to definition manual pages 48-49, 64 921. Crime resulting in death or serious injury, as defined in 915- 919. Refer to definition manual pages 48-49, 65
Refer to definition manual pages 48-49, 66 |
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923. Elopement from the hospital resulting in death or serious injury as defined in 915-919.
Refer to definition manual pages 48-49, 67 938. Malfunction of equipment during treatment or diagnosis or a defective product which resulted in death or serious injury as described in 915-919. Please include:
Refer to definition manual pages 48-49, 74
Refer to definition manual pages 48-49, 75 Refer to definition manual pages 48-49, 76 Refer to definition manual pages 48-49, 77 |
923. Cases in which the patient outcome would have been the same whether or not the elopement occurred (cancer death, etc.). | |
Submit Short Form Only Root Cause Analysis Not Required |
Refer to definition manual page 50 |
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902. Patients transferred to the hospital from a diagnostic and treatment center.
FOR INTERNAL DOH USE ONLY Refer to definition manual page 51 |
902. Planned hospital admission from a diagnostic and treatment center. | |
Refer to definition manual page 55-57 931. Strike by hospital staff. Refer to definition manual page 68 |
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932. External disaster outside the control of the hospital which affects facility operations.
Refer to definition manual page 69 |
932. Situations that are related to termination of service should be reported under 933. | |
933. Termination of any services vital to the continued safe operation of the hospital or to the health and safety of its patients and personnel, including but not limited to the anticipated or actual termination of telephone, electric, gas, fuel, water, heat, air conditioning, rodent or pest control, laundry services, food or contract services.
Refer to definition manual page 70
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933. Excludes services maintained by back up services (e.g., back up generator or O2 supply), have no impact on the safe operation of the hospital, or on the health and safety of its patients or staff. | |
Submit Short Form Only
Root Cause Analysis Not Required |
Refer to definition manual page 71 Refer to definition manual page 72 937. Malfunction of equipment during treatment or diagnosis or a defective product which has a potential for adversely affecting patient or hospital personnel or a resulting in a retained foreign body. Please include:
Refer to definition manual page 73 |
SPECIFIC PROCEDURES FOR CODE 605 | ||
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NOTE: Consider code 915 in addition to 605 if death is unexpected and not directly related to the natural course of the patient’s illness or underlying disease process (even if the procedure is not included in the specific list below). | ||
Procedures | ICD-9 Code Range | Examples |
Appendectomy | 47.0-47.19 | Laparoscopic A. Incidental A. |
Non-Cardiac Arteriography (Angiography) | 88.4-88.49 | Aortography |
Cholecystecomy | 51.2-51.24 | Laparoscopic C. |
Endarterectomy | 38.10-38.19 | of Vessels of Arteries of Veins |
Resection Of Large Intestine | 45.7-45.8 | Cecectomy Right Hemicolectomy Resection of Transverse Colon Left Hemicolectomy Sigmoidectomy Total Colectomy |
Hysterectomy | 68.3-68.7, 68.9 | Subtotal Abdominal Vaginal Laparoscopic Total Radical |
Large Bowel Endoscopy | 45.23-45.24 | Colonoscopy Sigmoidoscopy |
Prostatectomy | 60.2-60.69 | Transmurethral Suprapubic Retropubic Radical Perineal |
Replacement of Joint of Lower Extremity | 81.5-81.59 | Total Hip Partial Hip Revision of Hip Total Knee Revision of Knee Total Ankle Replacement in Toe or Foot |
Spinal Fusion | 81.0-81.09 | Atlas-axis Anterior technique Posterior technique Dorsal/Dorsolumbar Lumbar/Lumbosacral, Revision |