Health-care incident or allegation type code NN[N]

Guide for use:

CODE 10 Diagnosis

'Diagnosis' includes missed, delayed or incorrect diagnosis.

'Medication-related' is defined to cover the use of drugs and other medicines in the delivery of health services, including immunisations; excludes 'anaesthetic' and 'blood or blood product-related'.

CODE 20 Medication-related: type and dosage

'Medication-related: type and dosage' includes issues related to type of medication or its dosage.

CODE 21 Medication-related: method of administration

'Medication-related: method of administration' includes issues related to method of administration of medication.

CODE 22 Medication-related: other or not further defined

'Medication-related: other or not further defined' includes any medication-related issues other than type, dosage or method of administration. Examples include medication not provided and a patient's reaction to a correctly prescribed and administered medication.

CODE 30 Anaesthetic

'Anaesthetic' includes all issues related to epidural, anaesthetic substances, equipment, monitoring or resuscitation and patient awareness.

‘Procedure’ is defined as an invasive clinical intervention, where there is an incision and/or the body cavity is entered; procedures may be therapeutic or diagnostic. A vaginal delivery is also considered a procedure for the purposes of this metadata item.

CODE 51 Procedure—wrong procedure

'Procedure—wrong procedure' includes unnecessary procedures, for example, removal of a healthy appendix.

CODE 53 Procedure—post-operative complications

'Procedure—post-operative complications' includes incidents involving unintentionally retained objects following a procedure.

CODE 56 Procedure—post-operative infection

'Procedure—post-operative infection' includes wound infection due to a procedure; excludes hospital-acquired infections, for example, post-operative sepsis, needlestick injuries and claims involving failure to properly sterilise equipment.

CODE 57 Procedure—intra-operative complications

'Procedure—intra-operative complications' includes complications that arise during the course of a procedure, for example unintended perforations of adjacent organs.

CODE 59 Procedure—other or not further defined

'Procedure—other or not further defined' includes alleged negligent procedure (where no further information is available).

'Treatment' refers to health-care acts other than 'medication-related', 'anaesthetic', 'blood or blood product-related (includes blood transfusions)' or 'procedure'. Examples of treatment include applying a dressing to a wound, setting a broken bone, physiotherapy services and psychiatric counselling for mental health patients.

CODE 61 Treatment—not provided

'Treatment—not provided' includes, for example, where an ambulance is called to attend but does not arrive, where a patient's condition deteriorates after the patient elects to leave or is turned away from a medical facility, or where a patient is not provided with the diet required by the patient's condition.

CODE 62 Treatment—complications

'Treatment—complications' includes, for example, developing ulcers under a plaster or dressing or a bone fractured during physiotherapy treatment, or where the failure to clean a wound sustained from an injury results in infection.

CODE 63 Treatment—failure of treatment

'Treatment—failure of treatment' includes incorrectly setting a broken bone.

CODE 64 Treatment—other or not further defined

'Treatment—other or not further defined' includes any incident or allegation of treatment as defined here, which does not fall under the treatment subcategories listed above.

CODE 70 Consent (includes failure to warn)

'Consent (includes failure to warn)' includes no valid consent and failure to warn, cessation or continuation of treatment without consent or against patient’s stated wishes, and disposing of a fetus without the consent of the parents.

CODE 80 Infection control (includes instrument sterilisation)

'Infection control (includes instrument sterilisation)' includes hospital-acquired infections, for example, post-operative sepsis, needlestick injuries and claims involving failure to properly sterilise equipment, but excluding post-operative infection.

CODE 90 Device failure (includes problems with implanted devices)

'Device failure (includes problems with implanted devices)' includes device failure during insertion and the insertion procedure is consequently aborted. Excludes problems due to the surgical implantation procedure.

CODE 100 Other general duty of care issues

'Other general duty of care issues' includes falls, administrative errors, for example, placing a ‘nil by mouth’ sign on the bed of the wrong patient, and patient monitoring and follow-up issues.

CODE 888 Other

'Other' includes medico-legal reports, disciplinary enquiries and other legal issues, breach of confidentiality, record keeping or loss of documents, and harassment and discrimination.

CODE 999 Not stated/inadequately described

'Not stated/inadequately described' should be used when the information is not currently available.

Comments:
The definition of 'Procedure' used in the Medical indemnity data set specification was agreed to by the MIDWG during the data development phase of the MINC. This definition is narrower than the definition of 'Procedure' used in the National Health Data Dictionary METeOR identifier 391349.