Extent of harm from a health-care incident code N[N]

Identifying and definitional attributes

Metadata item type:Value Domain
METeOR identifier:329592
Registration status:Health, Standard 07/12/2011
Definition:A code set representing the extent of harm from a health-care incident.

Representational attributes

Representation class:Code
Data type:Number
Format:N[N]
Maximum character length:2
Permissible values:
ValueMeaning
4Death
7Mild injury
8Moderate injury
9Severe injury
Supplementary values:
97Not applicable (no body function or structure affected)
99Not stated/inadequately described

Collection and usage attributes

Guide for use:

CODE 7   Mild injury

'Mild injury' includes situations where the harm results in a mild variation (up to 25%) from accepted population standards in the status of the affected body function or structures.

'Mild' refers to an intensity that a person can tolerate, and is unlikely to be permanent. This category could include, for example, the situation where a patient has suffered mild psychological harm as a result of a misdiagnosis by a general practitioner.

CODE 8   Moderate injury

'Moderate injury' includes situations where the harm results in a moderate variation (between 25–50%) from accepted population standards in the status of the affected body function or structures.

'Moderate' refers to a problem with an intensity which interferes with the person’s day to day life, and which may be permanent. This may include, for example, a situation where a patient is administered a medication that was clearly contraindicated, which results in a moderate impairment of hepatic function. 

CODE 9   Severe injury

'Severe injury' includes situations where the harm results in a severe variation (more than 50%) from accepted population standards in the status of the affected body function or structures.

'Severe' refers to a problem that has an intensity that partially or completely disrupts the person’s day to day life, and which is likely to be permanent. This could include, for example, a situation where an accidental cut, puncture or perforation which occurred during surgery leads to a severe permanent impairment of lower limb function.

In cases where the patient has pre-existing impairments, activity limitations and/or participation restrictions, the coding category chosen should reflect only the additional harm or disability due to the incident, over and above any pre-existing conditions.

CODE 97   Not applicable (no body function or structure affected)

'Not applicable (no body function or structure affected)' includes cases where there is no consequent harm to body functions or structures; for example, failed sterilisation procedure or awareness during a procedure due to anaesthetic failure.

CODE 99   Not stated/inadequately described

'Not stated/inadequately described' should be used when the information is not currently available. This code should also be used where the medical indemnity claim is for fetal distress and the outcome for the child will not be known until some future time.

Comments:

The coding categories were developed with reference to the WHO (2003) 'Activity Limitations and Participation Restriction' definitions (ICF Version 2.1a) for 'Mild difficulty', 'Moderate difficulty', 'Severe difficulty' and 'Complete difficulty'.

The categories in this value domain align with the categories in the Australian Prudential Regulation Authority (2006) National Claims and Policies Database data item 17 'Severity of loss'.

Source and reference attributes

Submitting organisation:Australian Institute of Health and Welfare
Steward:Australian Institute of Health and Welfare
Reference documents:

APRA (Australian Prudential Regulation Authority) 2006. Data Specifications National Claims and Policies Database document number 3.1. Canberra: APRA

WHO (World Health Organization) 2003. International Classification of Functioning, Disability and Health. Geneva: WHO

Relational attributes

Data elements implementing this value domain:

Patient—extent of harm from a health-care incident, code N[N] Health, Standard 07/12/2011