Table 2 Examples for the ICD-11 quality and safety coding model

Surgical or other medical procedure

Example 1 A patient visits a primary care physician for removal of a skin lump, mainly to exclude the possibility of malignancy. The lesion is excised and the wound is sutured. It later becomes known that the physician had Hepatitis C and the patient has now contracted this disease

Harm Acute hepatitis C 1E50.2

Cause Biopsy procedure, not elsewhere classified, associated with injury or harm in therapeutic use PK81.5

Mode Failure of sterile precautions, as mode of injury or harm PL11.4

Code Structure: 1E50.2/PK81.5/PL11.4

Example 2 An patient is admitted due to a fractured neck of femur. Surgical fixation is undertaken. The operative site bleeds heavily the day after surgery, requiring return to theatre

Harm Haemorrhage not elsewhere classified MG27

Cause Musculoskeletal procedure associated with injury or harm, open approach PK80.80 (Orthopaedic surgical procedures are included here)

Mode Unspecified mode of injury or harm associated with a surgical or other medical procedure P11.Z (Note: Select PL11.Z because case documentation does not mention any specific mode or mechanism by which haemorrhage occurred)

Code Structure: MG27/ PK80.80/PL11.Z

Surgical or other medical device, implant or graft

Example 3 A patient had a left knee-replacement less than a year ago, because of arthritis. The implanted device has come loose, resulting in pain and reduced function

Harm Pain in joint ME82; Specific Anatomy (use additional code, if desired) Knee joint XA8RL1; Laterality (use additional code, if desired)—Left XK8G

Cause Orthopaedic devices associated with adverse incidents, prosthetic or other implants, materials or accessory devices PK99.2

Mode Dislodgement, misconnection or de-attachment, as mode of injury or harm PL12.4

Code Structure: ME82&XA8RL1&XK8G/PK99.2/PL12.4

Example 4 Refractory urinary tract infection due to chronic indwelling catheter

Harm Urinary tract infection, site and agent not specified GC08.Z

Cause Gastroenterology or urology devices associated with adverse incidents, urinary catheter PK93.10

Mode Other specified mode of injury or harm associated with a surgical or other medical device, implant or graft PL12.Y (Note: Select PL12.Y because none of the more specific mode types appears to lead to infection of device)

Code Structure: GC08.Z/PK93.10/PL12.Y

Drug, medicament or biological substance

Example 5 A patient has been admitted to hospital for stabilisation of diabetes. They are erroneously prescribed three times the usual dose of an antidiabetic medication. The abnormally high dose is given, and the patient has a hypoglycaemic episode

Harm Hypoglycaemia in the context of diabetes, unspecified 5A21

Cause Drugs, medicaments or biologic substances associated with injury or harm in therapeutic use PL00; Medication (use additional code, if desired)—Antidiabetic XM8S35

Mode Overdose of substance as mode of injury or harm PL13.0

Code Structure: 5A21/PL00&XM8S35/PL13.0

Example 6 Patient presented to hospital with hallucinations due to malaria prophylaxis with mefloquine prescribed and taken at the correct dose

Harm Visual hallucinations MB27.27

Cause Drugs, medicaments or biological substances associated with injury or harm in therapeutic use PL00; Medication (use additional code, if desired)—Mefloquine XM50J2

Mode Drug-related injury or harm in context of correct administration or dosage, as mode of injury or harm PL13.2

Code Structure: MB27.27/PL00&XM50J2/PL13.2

Other healthcare-related causes

Example 7 Patient falls out of bed in a hospital and suffers a left hip fracture. The documentation describes that the nurse forgot to put the bedrails in place which lead to the patients fall

Harm Fracture of neck of femur, unspecified NC72.2; Laterality (use additional code, if desired)—Left XK8G

Cause Other healthcare-related causes of injury or harm PL10

Mode Fall in healthcare PL14.E

Code Structure: NC72.2&XK8G/PL10/PL14.E

Example 8 Patient received an infusion of red blood cells and develops severe rigors that subside after an hour. It was discovered that there was a blood mismatch (not ABO or Rh incompatibility)

Harm Other serum reactions NE80.3

Cause Other healthcare-related causes of injury or harm PL10

Mode Mismatched blood used in transfusion PL14.3

Code Structure: NE80.3/PL10/PL14.3