Development of the Korean Patient Safety Incidents Code Classification System

Patient safety is the most basic requirement of providing adequate health care.1,2 However, it is not easy to obtain a comprehensive understanding of patient safety level. Thus, various methodologies such as analyses of medical malpractice litigation,3 reporting and learning systems for patient safety incidents,4 assessments of administrative data,5,6 and review of medical records7 have been used. Each method has its own strengths and weaknesses, and their interpretations vary depending on the type of patient safety incident.8 This means that there is no one-size-fits-all approach to quantifying the level of patient safety. It also means choosing an appropriate method according to the purpose of the measurement.

Among the various methods for identifying the patient safety status, the method of analyzing administrative data is an approach that can comprehensively examine the patient safety status at the population level.9 Approaches to this analysis such as using diagnosis codes for examining insurance claims are relatively inexpensive and easy to perform compared with other methods. Hence, studies examining patient safety by analyzing administrative data have been used to distinguish the various types of patient safety incidents, such as drug adverse effects and healthcare-associated infections.10,11

Furthermore, monitoring patient safety incidents using diagnosis codes can also serve as a tool for comparing patient safety in different countries. Attempts to quantify the burden of disease caused by patient safety incidents have been based on methods estimating the burden for different modeling methods.12,13 In these methods, diagnosis codes play a critical role in defining the incidence or prevalence of patient safety incidents.14 The aim to compare the global disease burden caused by patient safety incidents implies a need for a monitoring system using diagnosis codes.

However, it is well known that international discrepancies in interpreting and using the International Classification of Diseases (ICD).15,16 Previous studies to identify the full range of patient safety incidents using administrative data are limited, and they used their own diagnosis codes in each country such as ICD, Ninth Revision, Clinical Modification (ICD-9-CM),17ICD Tenth Revision, Australian Modification (ICD-10-AM),18 and ICD Canadian Version of 10th Revision (ICD-10-CA).19 Therefore, it is necessary to develop a patient safety incident code classification system in each country and continue to research and develop methods for better comparison by mapping the codes.

In Republic of Korea (hereinafter Korea), there have been attempts to understand patient safety using administrative data. Some studies have aimed at examining the occurrence of 6 types of patient safety incidents using the ICD-10 codes found in the National Health Insurance Service–National Sample Cohort5 and introducing patient safety indicators using the Korean National Hospital Discharge In-depth Injury Survey.20 However, there is still need for conducting a comprehensive exam of patient safety using administrative data. In particular, it is necessary to review whether the administrative diagnosis codes used in previous studies sufficiently cover the various types of patient safety incidents.

Thus, this study aimed to develop and identify the characteristics of a Korean patient safety incident code classification system to more easily identify whether a patient safety incident has occurred using diagnosis codes.

METHODS The Concept of the Study

In this study, according to the definition stipulated by the World Health Organization, a patient safety incident was defined as “an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient.”21 That is, the concept of a patient safety incident includes both adverse events and near misses.

This study also assumed that there were data for the present on admission (POA) that identified whether the diagnosis code existed before the time of admission,22 and if the diagnosis code is considered to have occurred after admission, the code was classified as a patient safety incident. In these cases, the POA of the diagnosis code is tagged as “N.”

Figure 1 shows the logical structure that allows us to determine whether a patient safety incident has occurred using the Korean patient safety incident code classification system derived from this study.

F1FIGURE 1:

Process of determining whether a patient safety incident has occurred based on the patient safety incident code classification system.

Search and Review of Candidate Patient Safety Incident Codes

One researcher mapped the ICD-10 codes established in previous studies to identify patient safety incidents from 54,259 Korean Standard Classification of Diseases 7 (KCD-7) codes and selected 4557 codes for analysis after eliminating the duplicates.10,14,19,23 The selected codes were evaluated for the probability score as a patient safety incident as follows: (1) patient safety incident highly likely, (2) patient safety incident likely, (3) possible patient safety incident, (4) previously reported as patient safety incident (cannot exclude the possibility of patient safety incident), and (5) no KCD-7 code available. The codes included after review were used in the Delphi review described hereinafter as candidate codes for the Korean patient safety incident code classification system.

Delphi Review of Candidate Patient Safety Incident Codes

The Delphi review of the candidate codes was conducted by experts with extensive research and practical experience in patient safety and the KCD-7 code classification system. A total of 5 experts participated in the review: 1 emergency medicine specialist, 1 preventative medicine specialist, 2 nursing professors, and 1 health information manager.

Before beginning the review, a meeting was held with the experts to introduce the study content. The first round of the Delphi review involved an anonymized evaluation of the probability of a patient safety incident of the Korean patient safety incident candidate codes. The reviewers used a 4-point rating scale to respond to the following questions: How appropriate is the probability score assigned to the code as a patient safety incident? How much do you agree with that score? The rating scale consisted of the following: strongly agree (1 point), agree (2 points), disagree (3 points), and strongly disagree (4 points). If applicable, reviewer comments for revisions on the probability score as a patient safety incident were collected separately.

In the second round of review, the results from the first round were anonymously shared with the reviewers, giving them the opportunity for suggesting revisions. Each round of the review lasted for approximately 1 month, and on average, 2 reminder emails were sent to the reviewer per round. Reviewer agreement was operationally defined as cases in which the coefficient of variation of the response was less than 0.5. One researcher reviewed and organized the results of the 2 rounds of the Delphi review and developed the Korean patient safety incident codes.

Categorization of Patient Safety Incident Codes

The researchers classified the Korean patient safety incident codes identified through the Delphi review based on the categories used in previous studies.7,18,19,24–27 The codes were classified into the most appropriate category based on the categorical name, description, and reviewer comments. For instance, if the categorical name, description, or comments included the key word, “drug-induced,” the code was classified as a drug-related complication.

In addition, to increase the use of this classification system, the Korean patient safety incident codes were divided into code groups and candidate groups based on the probability score as a patient safety incident. The codes with probability score of 3 or lower were included as the code groups of the Korean patient safety incident code, while those with a score of 4 were included as the candidate groups. Forty-eight codes with the probability score of 5 were excluded, because they could be found in the ICD-10 codes but not in the KCD-7.

Ethics Committee Approval

This study was approved by the institutional review boards of each participating hospital and of the National Evidence-Based Healthcare Collaborating Agency (approval number: NECAIRB18-020-10). 

RESULTS The Korean Patient Safety Incident Code Classification System

The Korean patient safety incident codes were classified into 6 categories and 35 subcategories (Table 1). The entire list of codes can be found in the supplement (Supplemental File 1, https://links.lww.com/JPS/A529).

TABLE 1 - The Korean Patient Safety Incident Code Classification System Category Subcategory 1. Diagnosis-related incidents 1.1 Non-administration of surgical and medical care 2. Medication-, fluid-, and blood-related incidents 2.1 Infusion/injection complications 2.2 Drug-related complications 2.3 Transfusion-related complications 2.4 Others 3. Patient care–related incidents 3.1 Decubitus ulcer 3.2 Delirium 3.3 Falls 3.4 Patient accidents 3.5 Sequelae of events 3.6 Others 4. Operation- and procedure-related incidents 4.1 Anesthesia-related complications 4.2 Hemorrhage-related complications 4.3 Puncture/amputations/injuries during the procedure 4.4 Foreign body or substance left following the procedure 4.5 Disruption and infection of operation wound 4.6 Pregnancy- and childbirth-related complications 4.7 Implants-related complications 4.8 Procedure-related complications 4.9 Post-procedural complications 4.10 Medical device–related complications 4.11 Radiation-related complications 4.12 Other complications 5. Infection-related incidents 5.1 Sepsis 5.2 Pneumonia 5.3 Intestinal infectious diseases 5.4 Urinary tract infection 5.5 Infectious agents 5.6 Other infections 6. Others 6.1 Endocrine, nutritional, and metabolic disease 6.2 Circulatory system diseases 6.3 Respiratory system diseases 6.4 General symptoms and signs 6.5 Patient status
The Distribution of Korean Patient Safety Incident Codes Into Categories

There are 4509 Korean patient safety incident codes, of which 2435 belong to code groups (54.0%) and 2074 to candidate groups (46.0%; Table 2). The major categories of patient safety incidents, in the order of frequency, involved medication, fluid- and blood-related (1719 codes, 38.1%), operation- and procedure-related (1339 codes, 29.7%), and patient care–related (991 codes, 22.0%). Meanwhile, there were only 2 codes related to diagnosis. Regarding only the code groups, medication-, fluid-, and blood-related incidents comprised more than half of the 2435 codes (1291 codes, 53.0%); 973 codes (40.0%) were medication-, fluid-, and blood-related incidents, and 53 (2.2%) codes were related to patient care.

TABLE 2 - Patient Safety Incident Categories With Code Numbers of PSI Codes Categories Total Code Group Candidate Group n % n % n % 1. Diagnosis-related incidents 2 0.0 2 0.1 0 0.0 2. Medication-, fluid-, and blood-related incidents 1719 38.1 1291 53.0 428 20.6 3. Patient care-related incidents 991 22.0 53 2.2 938 45.2 4. Operation- and procedure-related incidents 1339 29.7 973 40.0 366 17.6 5. Infection-related incidents 203 4.5 108 4.4 95 4.6 6. Others 255 5.7 8 0.3 247 11.9 Total 4509 100.0 2435 100.0 2074 100.0

PSI, patient safety incident.


Distribution of Korean Patient Safety Incident Codes Into Subcategories

Table 3 presents the Korean patient safety incident codes as subcategories. In the case of diagnosis-related patient safety incidents, there was only 1 subcategory—“nonadministration of surgical and medical care”—and 2 codes, both of which were in the code group. In medication-, fluid-, and blood-related incidents, “drugs-related complications” was the most common category, having 1119 codes. In contrast, “infusion/injection complications” consisted of only 35 codes, but all were included in the code group. Patient care–related incidents were mainly classified as patient accidents, but only 29 codes were included in the code group. Operation- and procedure-related incidents involved 333 “postprocedural complications” and 225 “pregnancy and childbirth-related complications.” Not only are these numbers of codes quite substantial, but most of the codes in these subcategories were classified into the code group, which indicated a high probability of patient safety incidents. Although there were 202 codes in “puncture/amputations/injuries during procedures,” only around a quarter of these were classified into the code group. For infection-related incidents, “other infections” were the most common with 119 codes. Although 26 codes were identified for “sepsis,” a hospital-acquired infection, all of them were classified as candidates. Meanwhile, all 21 codes for “pneumonia” were classified as codes. For “other” patient safety incidents, many of the codes were pertaining to diseases or patient conditions, and most were classified as candidate codes.

TABLE 3 - Patient Safety Incident Subcategories With Code Numbers of PSI Codes Subcategories Total Code Group Candidate Group n % n % n % Diagnosis-related incidents  Nonadministration of surgical and medical care 2 0.0 2 0.1 0 0.0 Medication-, fluid-, and blood-related incidents  Infusion/injection complications 35 0.8 35 1.4 0 0.0  Drug-related complications 1119 24.8 950 39.0 169 8.1  Transfusion-related complications 15 0.3 14 0.6 1 0.0  Others 550 12.2 292 12.0 258 12.4 Patient care–related incidents  Decubitus ulcer 14 0.3 14 0.6 0 0.0  Delirium 14 0.3 5 0.2 9 0.4  Falls 3 0.1 0.0 3 0.1  Patient accidents 955 21.2 29 1.2 926 44.6  Sequelae of events 1 0.0 1 0.0 0 0.0  Others 4 0.1 4 0.2 0 0.0 Operation- and procedure-related incidents  Anesthesia-related complications 74 1.6 73 3.0 1 0.0  Hemorrhage-related complications 11 0.2 3 0.1 8 0.4  Puncture/amputations/injuries during procedure 202 4.5 36 1.5 166 8.0  Foreign body or substance left following the procedure 21 0.5 20 0.8 1 0.0  Disruption and infection of operation wound 5 0.1 3 0.1 2 0.1  Pregnancy- and childbirth-related complications 225 5.0 221 9.1 4 0.2  Implant-related complications 135 3.0 97 4.0 38 1.8  Procedure-related complications 63 1.4 33 1.4 30 1.4  Post-procedural complications 331 7.3 320 13.1 11 0.5  Medical device–related complications 67 1.5 67 2.8 0 0.0  Radiation-related complications 24 0.5 23 0.9 1 0.0  Other complications 181 4.0 77 3.2 104 5.0 Infection-related incidents  Sepsis 26 0.6 0.0 26 1.3  Pneumonia 21 0.5 21 0.9 0 0.0  Intestinal infectious diseases 16 0.4 3 0.1 13 0.6  Urinary tract infection 2 0.0 2 0.1 0 0.0  Infectious agents 19 0.4 9 0.4 10 0.5  Other infections 119 2.6 73 3.0 46 2.2 Others  Endocrine, nutritional, and metabolic disease 79 1.8 6 0.2 73 3.5  Circulatory system diseases 73 1.6 2 0.1 71 3.4  Respiratory system diseases 4 0.1 0.0 4 0.2  General symptoms and signs 4 0.1 0.0 4 0.2  Patient status 95 2.1 0.0 95 4.6
Distribution of Korean Patient Safety Incident Codes Through KCD-7 Classification

The code and candidate groups comprised 4.5% (2435 codes) and 3.9% (2074 codes) of the 54,259 KCD-7 codes, respectively (Table 4). More specifically, an exam of the distribution of the Korean patient safety incident codes through KCD-7 classification revealed that “injury, poisoning, and other specific outcomes (S00–T98)” was the most common at 27.7%, followed by “extrinsic cause of morbidity and mortality (V01–Y98)” (16.1%) and “diseases of the musculoskeletal system and connective tissue (M00–M99)” (11.2%). An exam of the Korean patient safety incident codes through the KCD-7 classification demonstrated that 14.0% of the “pregnancy- and childbirth-related complications (O00–O99)” were considered codes, which made up the highest proportion. The second most prevalent KCD-7 classification was “specific conditions originating from the perinatal period (P00–P96).” With reference to the KCD-7 classification, 14.8% of the candidate codes in “factors affecting health status and exposure to health services (Z00–Z99)” and 14% of the candidate codes in “injury, poisoning, and other specific outcomes (S00–T98),” which made up a high proportion of the candidate group.

TABLE 4 - Korean Standard Classification of Diseases 7 Categories With Code Numbers Included in PSI Codes Category KCD-7 Codes PSI Codes Total Code Group Candidate Group n n % Category Included n % Category Included n % Category Included 1 Infectious and parasitic diseases (A00–B99) 2212 140 6.3 88 4.0 52 2.4 2 Neoplasms (C00–D48) 2084 0 0.0 0 0.0 0 0.0 3 Blood diseases (D50–D89) 572 73 12.8 62 10.8 11 1.9 4 Endocrine (E00–E90) 3054 194 6.4 121 4.0 73 2.4 5 Mental and behavioral (F00–F99) 1669 183 11.0 42 2.5 141 8.4 6 Nervous system (G00–G99) 1049 91 8.7 83 7.9 8 0.8 7 Eye and adnexa (H00–H59) 1104 105 9.5 25 2.3 80 7.2 8 Ear and mastoid process (H60–H95) 397 13 3.3 12 3.0 1 0.3 9 Circulatory system (I00–I99) 1235 167 13.5 75 6.1 92 7.4 10 Respiratory system (J00–J99) 1002 88 8.8 56 5.6 32 3.2 11 Digestive system (K00–K93) 2162 248 11.5 219 10.1 29 1.3 12 Skin and subcutaneous tissue (L00–L99) 887 76 8.6 58 6.5 18 2.0 13 Musculoskeletal system (M00–M99) 17,455 505 2.9 417 2.4 88 0.5 14

留言 (0)

沒有登入
gif