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

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'.