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Tennessee Reportable Unusual Events

Occurrence Codes ‘Includes / Excludes’

Adapted from Tennessee
[Interpretive Guidelines for Reporting Unusual Events (rev. January 2005)]
Medication Errors
Topical, Injectables, IV, PO
Treatment Medications, contrasts, chemotherapy
1. 108. A medication error occurred that resulted in permanent patient harm.
Any adverse drug reaction that was not the result of a medication error.
2. 109. A medication error occurred that resulted in a near-death event
(e.g., an aphylaxis, cardiac arrest).
An allergic reaction in a case where patient did not know of allergy prior to administration of the pharmaceutical agent.
3. 110. A medication error occurred that resulted in a patient death.
4. 201. Aspiration pneumonitis / pneumonia in a non-intubated patient related to conscious sedation.
Patients intubated on ventilation, or with known history of chronic aspiration.
Intravascular Catheter Related
5. 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).
Any infiltration or infection treated exclusively with cold or warm packs, wound irrigation, IV change, and/or medication use (e.g., IV, PO, topical), AV fistula revisions (renal dialysis).
6. 302. Volume overload leading to pulmonary edema.
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.
7. 303. Pnuemothorax, regardless of size or treatment
(including pneumothoraces resulting from a procedure performed through an intravascular catheter, e.g., temporary pacemaker insertion).
Non-intravascular catheter related pneumothoraces such as those resulting from lung biopsy, thoracentesis, permanent pacemaker insertion, etc.
Blood Transfusion Reactions 8. 403. Blood transfusion reactions related to wrong type of blood.
9. 404. Blood transfusion related to outdated blood, wrong patient.
Perioperative / Periprocedural Related
  • •  Occurring within 48 hours after procedure
ESRD (End Stage Renal Disease) patients post dialysis treatment. (Include only if occurs while patient is in dialysis area.)
10. 601. Any new central neurological deficit.
(e.g., TIA, stroke, hypoxic/anoxic encephalopathy).
Central neurological deficits due to direct procedures on the central nervous system (e.g., tumor dissection or removal, Transient metabolic encephalopathy, ASA 4 and 5, and previously documented potential high risk outcome).
11. 602. Any new peripheral neurological deficit.
(e.g., palsy, paresis) with motor weakness.
Deficits due to operative or other procedure on a specific nerve (e.g., procedures involving neuorfibroma, acoustic neuroma, Sensory symptoms or deficits without motor weakness, numbness or tingling, alone, ASA 4 and 5, previously documented potential high risk outcome).

NOTE: Deficits due to central neurological insults (such as hemiparesis) are submitted as a 601.
12. 701. 2nd and/or 3rd degree burns.
1st degree burns. Sunburns of 1st and 2nd degree of cognitively alert and physically capable patients.
13. 751. Falls resulting in radiologically proven fractures, subdural or epidural hematoma, cerebral contusion, traumatic subarachnoid hemorrhage, and/or internal trauma
(e.g., hepatic or splenic injury).
Falls resulting in soft tissue injuries. Fractures resulting from prior pertinent pathological conditions.
Procedure Related
  • •  Regardless of setting
  • •  Within 30 days of the procedure
  • •  Include readmissions
14. 801. 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.
Non-serious injuries of known or unknown origin such as laceration, skin tears, or bruising.

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, or 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.
15. 803. Hemorrhage or hematoma requiring drainage, evacuation or other procedural intervention.
Expected nonsymptomatic blood loss related to the procedures
  • • post - cardio-pulmonary bypass blood dyscrasia
  • • related to disease process
16. 806. Displacement, migration or breakage of an implant, device, graft, or drain, whether repaired, intentionally left in place or removed.
Occurrences reported in 913 (retained foreign body) or occurrences due to equipment malfunction or defective product reported in 937 or 938.
17. 808. Post-op wound infection following clean or clean/contaminated case.
ASA class is required to be noted.
Contaminated or dirty case procedure.
18. 819. Any unexpected 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.)
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-Hodgkin's lymphoma). Excludes debridement, vascular cases where conservative approach tried first (thrombectomy, fem-pop bypass) but ultimately fails (BKA done as last resort).
19. 851. Post partum hysterectomy
20. 853. Ruptured uterus
21. 854. Circumcision requiring repair
22. 855. Incorrect procedure or incorrect treatment that is invasive.
Venipuncture for phlebotomy, diagnostic tests without contrast agents.
Other Serious Events 23. 901. All other unusual incidents or accidents warranting DOH notification, not covered by codes.
Occurrence with the administration of anesthesia only-code as 912.

Endoscopy- code as 912
24. 911. Wrong Patient, Wrong Site-Surgical Procedure
Occurrence with the administration of anesthesia only-code as 912.

Endoscopy- code as 912
25. 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.)
Foreign bodies retained due to equipment malfunction or defective product (report under 937 or 938) or those reported under 806.
  915 through 919:
Occurrence codes 915 through 919 result from any unexpected adverse occurrence not directly related to the natural course of the patient's illness or underlying condition
915 through 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, including cardiac diseases and Dementia DX.)

Any cases involving malfunction of equipment resulting in death or serious injury should be reported under 938.
26. 915. Death (e.g., brain death).
27. 917. Loss of limb or organ.
28. 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.
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.
29. 921. Crime resulting in death or serious injury, as defined in 915- 919.  
30. 922. Suicides and attempted suicides related to an inpatient hospitalization, with serious injury as defined in 915-919
31. 923. Elopement from the hospital resulting in death or serious injury as defined in 915-919.
Cases in which the patient outcome would have been the same whether or not the elopement occurred (cancer death, etc.)
32. 931. Strike by hospital staff.
33. 932. External disaster outside the control of the hospital which affects facility operations.
Situations that are related to termination of service should be reported under 933.
34. 933. Termination of any services vital to the continued safe operation of the facility 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.
35. 934. Poisoning occurring within the facility
(water, air, food or ingestion).
36. 935. Facility fire disrupting patient care or causing harm to patients or staff.
37. 936. All other fires.
38. 961. Infant Abduction.
39. 962. Adult Abduction.
40. 963. Rape by another patient or staff.
41. 964. Resident to resident altercations
(nursing homes, homes for the aged, ACLF, A&D facilities would only report those requiring physician interventions).
Resident/Patient to Resident/Patient with non-physician interventions and appropriate facility intervention
42. 966. Restraint related Incident  
43. 967. Infant Discharged to Wrong Family.
44. 968. Physical Abuse
45. 969. Sexual Abuse
46. 970. Verbal Abuse
47. 971. Neglect or Self-Neglect
48. 972. Misappropriation of Funds
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