Health-care-related harm: worked clusters

Two clusters from WHO

Two clusters from WHO's guide: an overdose, and a fall in hospital.

A prescribed overdose

Case one. A woman admitted for diabetes stabilisation is erroneously prescribed three times the usual dose of an antidiabetic medication, and has a hypoglycaemic episode. What are the harm, cause and mode? Pause.

• Record · Triple dose · Admitted for diabetes stabilisation, erroneously prescribed three times the usual dose of an antidiabetic; hypoglycaemic episode.
• Task · Pause · Harm, cause, mode?

Harm, cause, mode

The answer. Harm: hypoglycaemia in the context of diabetes. Cause: drug harm in therapeutic use, with the antidiabetic medication as an extension. Mode: overdose of substance. One cluster, with slashes between the three parts.

• 5A21.Z · Harm · Hypoglycaemia in diabetes
• PL00 · Cause · / · Drug harm in therapeutic use
• XM8S35 · Medication · & · Antidiabetic
• PL13.0 · Mode · / · Overdose

A fall in hospital

Case two. An elderly patient falls out of bed in hospital and fractures the left hip. The nurse forgot to put the bedrails in place. Pause.

• Record · Out of bed · An elderly patient falls out of bed and fractures the left hip; the nurse forgot the bedrails.
• Task · Pause · Harm, cause, mode?

An other cause

The answer. Harm: fracture of neck of femur, with laterality left. Cause: other health care related causes. Mode: fall in health care. Again, one cluster with a slash between the parts.

• NC72.2Z · Harm · Fracture of neck of femur
• XK8G · Laterality · & · Left
• PL10 · Cause · / · Other health care cause
• PL14.E · Mode · / · Fall in health care

Check yourself

Pause and think. An elderly patient falls out of bed because the bedrails were not in place. What is the cause? The answer: Other health care related causes. WHO's answer: harm fracture of neck of femur with laterality left, cause other health care related causes, mode fall in health care.

• Drug harm in therapeutic use
• Poisoning
• Other health care related causes
• Device failure

Keep these in mind

Harm first, with its own extensions. Then the cause, with any drug extension. Then the mode, separated by slashes.

• Harm first, with its own extensions
• Then the cause, with any drug extension
• Then the mode, separated by slashes