Appendix B

OCCURRENCE CODE INCLUDES EXCLUDES
Medication Errors:

Topical, Injectables, IV, PO

Treatment Medications, Contrasts, Chemotherapy

915-920 codes and Root Cause Analysis Required.
  1. A medication error occurred that resulted in permanent patient harm.

(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
110. A medication error occurred that resulted in a patient death.

Refer to definition manual pages 7-8
Aspiration
  1. Aspiration pneumonitis/pneumonia in a non-intubated patient related to conscious sedation.

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).
  1. Volume overload leading to pulmonary edema.

Refer to definition manual page 11
  1. Pulmonary edema clearly secondary to acute myocardial infarction. Pulmonary edema occurring in patients with previously known, predisposing conditions such as CHF, cardiac disease, renal failure, renal insufficiency or hemodynamic instability in critically ill patients.

Volume overload occurrences related to blood transfusion are reported to Blood and Tissue Resources Program only.
  1. Pneumothorax, regardless of size or treatment (including pneumothoraces resulting from a procedure performed through an intravascular catheter, e.g., temporary pacemaker insertion).

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

  • include readmissions within 30 days
401. New, acute pulmonary embolism, confirmed, or suspected and treated.

Refer to definition manual page 13
  1. New, acute pulmonary embolism is suspected cause of sudden death but there is no autopsy to confirm (consider code 915).

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

  • Occurring the same day as, or on the 1st or 2nd day after procedure
  • regardless of setting of operation or procedure
  • include readmissions.

600’s category

  
  1. Any new central neurological deficit (e.g., TIA, stroke, hypoxic/anoxic encephalopathy).

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

  1. Central neurological deficits due to direct procedures on the central nervous system (e.g., tumor dissection or removal). Transient metabolic encephalopathy.

Birth related neonatal events reported to Perinatal Data System (page 86).

  1. Cardiac related occurrences complications) reported in the cardiac reporting systems (refer to definition manual pages 77-82).

    2. 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.)

  2. NOTE:Consider the 911-963 codes when applicable
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).
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
Burns/Falls
  1. 2nd and/or 3rd degree burns.

Refer to definition manual page 25

 701 1st degree burns.
  1. Falls resulting in x-ray proven fractures, subdural or epidural hematoma, cerebral contusion, traumatic subarachnoid hemorrhage, and/or internal trauma (e.g., hepatic or splenic injury).

Refer to definition manual page 26
  1. Falls resulting in soft tissue injuries.

NOTE:Consider the 911-963 codes, when applicable

 
Procedure Related

  • Regardless of setting*

* Excludes code 808

  • Within 30 days of the procedure
  • Include readmission

 

800’s category

  1. Procedure related injury requiring repair, removal of an organ, or other procedural intervention.

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

  
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
  1. Occurrences reported in 913 (retained foreign body) or occurrences due to equipment malfunction or defective product reported in 937 or 938.

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.
807. Thrombosed distal bypass graftrequiring repair.

Refer to definition manual pages 27-28, 37

 807. AV grafts and fistulas used for dialysis.
  1. *Post-op surgical wound infection following clean or clean/contaminated case (performed in the O.R. or Surgical suite only) requiring drainage during the hospital stay or INPATIENT hospital admission within 30 days. ASA class is required to be noted.

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).
Procedure Related

  • Regardless of setting *

* Excludes code 808

  • Within 30 days of the procedure

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
  1. Non-anesthesia procedural interventions (e.g., ERCP) usually performed in special procedure rooms in larger hospitals but which are performed in the OR in a smaller hospital simply due to lack of specialized facilities.

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

  • Regardless of setting *

* Excludes code 808

  • Within 30 days of the procedure

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

  
  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.

  
 

911. Wrong Patient, Wrong Site-Surgical Procedure

Refer to definition manual pages 48-49, 52
  1. Occurrence with the administration of anesthesia only-code as 912.

Endoscopy- code as 912
  912. Incorrect Procedure or Treatment - Invasive

Refer to definition manual pages 48-49, 53
  1. Venipuncture for phlebotomy, diagnostic tests without contrast agents.

Transfusion related occurrences (report to Blood and tissue resources

program only).
  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:

  1. Death (e.g., brain death).

Report Death of fetus/neonate meeting the following criteria:

For live or still birth

  1. Greater than or equal to 28 weeks gestation.
  2. Greater than or equal to 1000 grams of weight

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.
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:

  1. Death (e.g., brain death).

Report Death of fetus/neonate meeting the following criteria:

For live or still birth

  1. Greater than or equal to 28 weeks gestation.
  2. Greater than or equal to 1000 grams of weight

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:

  1. Cardiac and/or respiratory arrest requiring BLS/ACLS intervention.

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.
  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.
 
  1. Loss or impairment of bodily functions (sensory, motor, communication or physiologic function diminished from level prior to occurrence) and present at discharge or for at least 2 weeks after occurrence if patient is not discharged.

Refer to definition manual pages 48-49, 63
  1. Bodily function at the same level as prior to the occurrence, impairment resolves by discharge or within two weeks if not discharged.

Excludes positioning parathesias.
  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

  1. Suicides and attempted suicides related to an inpatient hospitalization, with serious injury as defined in 915-919.

Refer to definition manual pages 48-49, 66

  
  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:

  1. equipment/device name
  2. manufacturer
  3. model #
  4. serial #

Refer to definition manual pages 48-49, 74

  1. Infant Abduction.

    2. Refer to definition manual pages 48-49, 75

  2. Infant discharged to wrong family.

    3. Refer to definition manual pages 48-49, 76

  3. Rape by another patient or staff. (Includes alleged rape with clinical confirmation)

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
  1. Serious occurrence warranting DOH notification, not covered by codes 911-963.

Refer to definition manual page 50

  
  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.
 
  1. Misadministration of radioactive material (as defined by BERP, Section 16.25, 10NYCRR).

Refer to definition manual page 55-57

931. Strike by hospital staff.

Refer to definition manual page 68

  
  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

 

 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
  1. Poisoning occurring within the hospital (water, air, food).

    2. Refer to definition manual page 71

  2. Hospital fire disrupting patient care or causing harm to patients or staff.

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:

  1. equipment/device name
  2. manufacturer
  3. model #
  4. serial #

Refer to definition manual page 73

  

SPECIFIC PROCEDURES FOR CODE 605
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