Appendix-F-BV-Protocol

NHSN Biovigilance Component
Protocol v1.3.1
www.cdc.gov/nhsn

Appendix F. NHSN Incident Codes (Based on MERS-TM & TESS)
Product Check-In
(Products Received from Outside Source)
PC 00 Detail not specified
PC 01 Data entry incomplete/not
performed/incorrect
PC 02 Shipment incomplete/incorrect
PC 03 Product and paperwork do not match
PC 04 Shipped under inappropriate
conditions
PC 05 Inappropriate return to inventory
PC 06 Product confirmation
PC 07 Administrative check (2nd check)
Product/Test Request
(Clinical Service)
PR 00 Detail not specified
PR 01 Order for wrong patient
PR 02 Order incorrectly entered online
+PR 03 Special needs not indicated on order
(e.g., CMV negative, auto)
PR 04 Order not done/incomplete/incorrect
PR 05 Inappropriate/incorrect test ordered
PR 06 Inappropriate/incorrect blood product
ordered
Sample Collection
SC 00 Detail not specified
+SC 01 Sample labeled with incorrect patient
name
+SC 02 Not labeled
+SC 03 Wrong patient collected
SC 04 Collected in wrong tube type
SC 05 Sample QNS
SC 06 Sample hemolyzed
+SC 07 Label incomplete/illegible/incorrect
(other than patient name)
SC 08 Sample collected in error
SC 09 Requisition arrived without samples
+SC 10 Wristband incorrect/not available
SC 11 Sample contaminated
Sample Handling
(Service Collecting Samples)
SH 00 Detail not specified
SH 01 Sample arrived without requisition
SH 02 Requisition and sample label don’t
match
+SH 03 Patient ID incorrect/illegible on
requisition
SH 05 No phlebotomist/witness identification
SH 06 Sample arrived with incorrect
requisition
SH 07 Patient information (other than ID)
missing/incorrect on requisition
SH 10 Sample transport issue
Sample Receipt
(Transfusion Service)
SR 00 Detail not specified
SR 01 Sample processed in error
SR 02 Historical review incorrect/not done
SR 03 Demographic review/data entry
incorrect/not done
SR 04 Sample incorrectly accessioned
(test/product)
SR 05 Duplicate sample sent

Sample Testing
(Transfusion Service)
ST 00 Detail not specified
ST 01 Data entry incorrect/not performed
ST 02 Appropriate sample checks not done
+ST 03 Computer warning overridden
ST 05 Sample tube w/incorrect accession label
+ST 07 Sample tubes mixed up
+ST 09 Test tubes mislabeled (wrong patient
name/number)
ST 10 Equipment problem
ST 12 Patient testing not performed
ST 13 Incorrect testing method chosen
ST 14 Testing performed incorrectly
ST 15 Test result misinterpreted
ST 16 Inappropriate/expired reagents used
ST 17 ABO/Rh error caught on final check
ST 18 Current and historical ABO/Rh don’t match
ST 19 Additional testing not performed
ST 20 Administrative check at time work
performed
ST 22 Sample storage incorrect/inappropriate
Product Storage
(Transfusion Service)
US 00 Detail not specified
US 01 Incorrect storage of unit in transfusion
service
US 02 Expired product in stock
US 03 Inappropriate monitoring of storage device
US 04 Unit stored on incorrect ABO shelf
Available for Issue
(Transfusion Service)
AV 00 Detail not specified
AV 01 Inventory audit
AV 02 Product status not/incorrectly updated in
computer
AV 03 Supplier recall
AV 04 Product ordered incorrectly/not submitted

Request for Pick-up
(Clinical Service)
RP 00 Detail not specified
RP 01 Request for pick-up on wrong
patient
RP 02 Incorrect product requested for
pick-up
RP 03 Product requested prior to obtaining
consent
RP 04 Product requested for pick-up
patient not available
RP 05 Product requested for pick-up IV
not ready
RP 06 Request for pick-up incomplete
RP 10 Product transport issue
Product Issue
(Transfusion Service)
UI 00 Detail not specified
UI 01 Data entry incomplete/incorrect
UI 02 Record review incomplete/incorrect
UI 03 Pick-up slip did not match patient
information
UI 04 Incorrect unit selected (wrong
person or right person, wrong order)
UI 05 Product issue delayed
+UI 06 LIS warning overridden
UI 07 Computer issue not completed
UI 09 Not/incorrect checking of unit and/or
patient information
UI 11 Unit delivered to incorrect location
UI 19 Wrong product issued
UI 20 Administrative review (self, 2nd
check at issue)
UI 22 Issue approval not
obtained/documented

Product Administration
(Clinical Service)
UT 00 Detail not specified
+UT 01 Administered product to wrong
Product Selection
patient
+UT 02 Administered wrong product to
(Transfusion Service)
SE 00 Detail not specified
patient
SE 01 Incorrect product/component selected
UT 03 Product not administered
SE 02 Data entry incomplete/incorrect
UT 04 Incorrect storage of product on floor
SE 03 Not/incorrect checking of product and/or
UT 05 Administrative review (unit/patient
patient information
at bedside)
SE 05 Historical file misinterpreted/not checked
UT 06 Administered product
SE 07 Special processing needs not checked
w/incompatible IV fluid
SE 09 Special processing needs not understood or UT 07 Administration delayed
misinterpreted
UT 08 Wrong unit chosen from satellite
SE 11 Special processing not done
refrigerator
UT 10 Administered components in
Product Manipulation
inappropriate order
(Transfusion Service)
UT 11 Appropriate monitoring of patient
UM 00 Detail not specified
not done
UM 01 Data entry incomplete/incorrect
UT 12 Floor/clinic did not check for
UM 02 Record review incomplete/incorrect
existing products in their area
UM 03 Wrong component selected
UT 13 Labeling problem on unit
UM 04 Administrative check at time of
UT 19 Transfusion protocol not followed
manipulation
Other
UM 05 Labeling incorrect
+UM 07 Special processing needs not checked
MS 99
+UM 08 Special processing needs misunderstood
or misinterpreted
+UM 09 Special processing not/incorrectly done

+ Indicates high-priority incidents. Individual incident reports must be completed for each.
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June 2011