Administrative
AD Codes
AD Codes
Per policy, pt was to be monitored for 15 minutes following vaccine administration, however RN let him leave after 5 minutes; he became lightheaded and passed out in parking lot.
What is AD1026
Policy/protocol not followed
Pt would not let medical staff perform exam during admission because he felt they were alien species trying to harm him
What is BR 2006
Patient Bizarre Behavior
Patient tripped and fell on an uneven sidewalk that was under construction when leaving medical clinic resulting in broken leg
What is EN1001
Failure to ensure safe environment-Buildings/Ground Maintenance
Pt brings a CD with MRI results to specialist, however, the specialist is unable to upload the images because the EMR system at his office is incompatible with the system where MRI was performed
What is EH1001
Lack of integration/incompatible systems
Pt with DNR status resuscitated following cardiac arrest
AD1013
DNR/end of life issues
Pt was frustrated by the challenges encountered when attempting to communicate with his PCP so he sought care from another provider.
What is BR2008
Patient factors – seeking other providers due to dissatisfaction with care
CT report sent to Dr John Smith instead of intended recipient, Dr Jeff Smith
CS3001
Clinician did not receive test results as report went to wrong clinician
Patient slipped and fell on floor outside of radiology department that had been recently mopped by housekeeping resulting in subdural hematoma
What is EN1005
Failure to ensure a safe environment – housekeeping
Patient’s electronic record reflects he has a history of melanoma, however, he had basal cell carcinoma and never had melanoma. Error is not identified and remains in record for years.
What is EH2003
Incorrect information in EHR
Pt sat in ED waiting room for 6 hours and finally left without being seen; later diagnosed with severe pneumonia
What is AD1014
Access-scheduling/waiting issues
Patient's family members were insulting and threatening to staff making delivery of care difficult
What is BR2011
Patient factors – family-related behavioral issues
Road closures due to a snowstorm delayed surgeon getting to OR for emergency procedure resulting in pt death
What is EN 2001
Weather related
RN ignored an EMR pop up alert regarding a patient allergy and erroneously administered medication to a patient with known allergy resulting in anaphylactic reaction
What is EH2005
EHR alert issues/fatigue – user-related
RN assigned to 5 patients in ICU
(standard ratio 1 RN:2 ICU patients)
What is
AD1015 Adequacy of staffing
Pt, a Jehovah's Witness, suffered hemorrhage after childbirth but repeatedly refused blood transfusions and died 6 days after delivery
What is BR2010
Patient factors – spiritual/cultural issues
Pt admitted to hospital for suspected stroke in April 2020. Roommate had Covid, pt was exposed and diagnosed with Covid several days after admission
CS9100
Nosocomial Infection
Wife (caretaker) not allowed to stay with husband who had advanced dementia during ED visit due to Covid restrictions; pt wandered out of ED into busy road and was hit by car
What is EN 2020
Covid-19 impact (without Covid-19 diagnosis)
Physician copies H&P from prior visit in EMR for patient with new findings on exam
What is EH2006
Pre-populating/copy and paste – EHR
Medical office had multiple staff resignations over 2 year period due to toxic work environment
What is AD1030
High turnover
Pt (teenage boy) found in room unresponsive, taken to ED where mom reported he overdosed; pt's father arrived at ED and stated pt did not take any drugs but had hit his head during football practice the day before
What is BR2013
Patient factors – patient/family gives inconsistent/incomplete medical history
Power grid in city is knocked out (reason unknown) and hospital has to run on generator power resulting in delay of non urgent surgeries
What is EN2009
External causes – other
Office staff develops system for faxing referrals directly to specialty offices because EMR referral process takes too long
What is EH2004
EHR/CPOE workarounds