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Allergic responses to prescription drugs are largely preventable, and incur significant cost to the community both financially and in terms of healthcare outcomes. The capacity to minimise the effects of repeated events rests predominantly with the reliability of allergy documentation in medical records and computerised physician order entry systems (CPOES) with decision support such as allergy alerts. This paper presents an overview of the nature and extent of adverse drug reactions (ADRS) in Australia and other developed countries, a discussion and evaluation of strategies which have been devised to address this issue, and a commentary on the role of coded data in informing this patient safety issue. It is not concerned with pharmacovigilance systems that monitor ADRs on a global scale. There are conflicting reports regarding the efficacy of these strategies. Although in many cases allergy alerts are effective, lack of sensitivity and contextual relevance can often induce doctors to override alerts. Human factors such as user fatigue and inadequate adverse drug event reporting, including ADRS, are commonplace. The quality of and response to allergy documentation can be enhanced by the participation of nurses and pharmacists, particularly in medication reconciliation. The International Classification of Diseases (ICD) coding of drug allergies potentially yields valuable evidence, but the quality of local and national level coded data is hampered by under-documenting and under-coding.

within Australia all unexpected deaths are investigated by the Coroners Court; specifically, the coroner investigates the identity of the deceased and the cause and circumstances of death. This 'unexpected death' category inevitably includes cases of self-harm and suicide. Concerns regarding the accurate reporting of national suicide statistics resulted in a review of the coding process undertaken by the Australian Bureau of Statistics (ABS), which produces the national statistics, and a formal Commonwealth Government Senate Inquiry in 2009. This article reflects data and opinions collected prior to the Senate Inquiry or the adjustment of the ABS coding processes, and explores the role of the Coroner in determining the intent of the deceased person and the role the National Coronial Information System (NCIS) 1 database plays in the provision of this information. At the Case Notification and Case Closure stages of the coronial process, administrative coders abstract from the coronial file the 'intent' of the deceased and enter the data into relevant administrative systems (which upload to the NCIS). The relevant intent code in the NCIS is 'Intentional Self-Harm', which incorporates deliberate actions of self-harm and suicide. A mixed-method study was employed to investigate anecdotal reports of a problematic coronial coding process surrounding this category of cases. A sample of Australian coroners ( n=16), and of the national population of NCIS coders (n=36), were surveyed using separate instruments, and an unobtrusive case review of sampled NCIS cases ( n= 127) reflecting nine key mechanisms-of-death, was undertaken. Each Australian state and territory has its own Coroners Act, none of which provides legislative direction regarding the determination of intent by the coroner. Neither the coroner-respondents nor the coders favoured a standard proforma to record 'intent'. In order to inform their classificatory decision-making regarding the deceased's 'intent', the coders need to abstract extensively from the entire case file, scrutinising documentary materials from different investigators. They rely primarily on the police report at Case Notification and the coroner's finding at Case Completion. Coders do not generally perceive the classification of 'intent' to be problematic; however, despite NCIS-provided coder (technical) support materials, there exist inconsistent coder work practices and, sometimes, absent documentary evidence reflecting lack of information for ascertainment and interpretation by the coroner, investigators, and forensic experts on the 'intent' of the deceased. The gap between what a coroner is legally required to document regarding 'intent' and what society needs to know for statistical and preventive purposes, seems problematic to bridge.

Falls are the leading cause of hospital-treated injuries in Australia. Injury surveillance data are analysed to identify common causes and types of fall injuries, risk factors for particular activities, location of injury occurrence, and age groups at risk of injury. External cause of injury data include cause of injury, place of occurrence, and activity when injured. These are collected in hospitals, where ICD-10-AM codes are assigned by Health Information Managers and clinical coders, based on medical record documentation. The current study examined the extent and quality of Victorian coded data on external cause of injury due to a fall, assessed its usefulness for injury prevention, and compared the Victorian and Australia-wide data. This involved an analysis, using the Victorian Admitted Episode Dataset, of 38,153 hospital separations in 2007–08 for fall injuries and a comparison with the 2003–04 national data. This showed similar usage of External cause codes in Victoria and Australia-wide. There was overuse of residual categories such as Other and Unspecified, these being assigned in 73.8% of separations in Victoria and 71.6% nationally. The problem of overuse of Unspecified external cause codes for hospitalised fall injuries is arguably multifactorial. Inevitably, this overuse reduces the value of the coded data for injury surveillance and prevention, and for monitoring of the public health.

The unimpeded functioning of hospital Health Information Services (HIS) is essential for patient care, clinical governance, organisational performance measurement, funding and research. In an investigation of hospital Health Information Services' preparedness for internal disasters, all hospitals in the state of Victoria with the following characteristics were surveyed: they have a Health Information Service/Department; there is a Manager of the Health Information Service/Department; and their inpatient capacity is greater than 80 beds. Fifty percent of the respondents have experienced an internal disaster within the past decade, the majority affecting the Health Information Service. The most commonly occurring internal disasters were computer system failure and floods. Two-thirds of the hospitals have internal disaster plans; the most frequently occurring scenarios provided for are computer system failure, power failure and fire. More large hospitals have established back-up systems than medium- and small-size hospitals. Fifty-three percent of hospitals have a recovery plan for internal disasters. Hospitals typically self-rate as having a 'medium' level of internal disaster preparedness. Overall, large hospitals are better prepared for internal disasters than medium and small hospitals, and preparation for disruption of computer systems and medical record services is relatively high on their agendas.

As coded clinical data are used in a variety of areas (e.g. health services funding, epidemiology, health sciences research), coding errors have the potential to produce far-reaching consequences. In this study the causes and consequences of miscoding were reviewed. In particular, the impact of miscoding due to inadequate medical documentation on hospital funding was examined. Appropriate reimbursement of hospital revenue in the casemix-based (output-based) funding system in the state of Victoria, Australia relies upon accurate, comprehensive, and timely clinical coding. In order to assess the reliability of these data in a Melbourne tertiary hospital, this study aimed to: (a) measure discrepancies in clinical code assignment; (b) identify resultant Diagnosis Related Group (DRG) changes; (c) identify revenue shifts associated with the DRG changes; (d) identify the underlying causes of coding error and DRG change; and (e) recommend strategies to address the aforementioned. An internal audit was conducted on 752 surgical inpatient discharges from the hospital within a six-month period. In a blind audit, each episode was re-coded. Comparisons were made between the original codes and the auditor-assigned codes, and coding errors were grouped and statistically analysed by categories. Changes in DRGs and weighted inlier-equivalent separations (WIES) were compared and analysed, and underlying factors were identified. Approximately 16% of the 752 cases audited reflected a DRG change, equating to a significant revenue increase of nearly AU$575,300. Fifty-six percent of DRG change cases were due to documentation issues. Incorrect selection or coding of the principal diagnosis accounted for a further 13% of the DRG changes, and missing additional diagnosis codes for 29%.The most significant of the factors underlying coding error and DRG change was poor quality of documentation. It was concluded that the auditing process plays a critical role in the identification of causes of coding inaccuracy and, thence, in the improvement of coding accuracy in routine disease and procedure classification and in securing proper financial reimbursement.

This paper explains how routinely collected data can be used to examine the emergency department attendances of Victorian Aboriginal and Torres Strait Islander people. The data reported in the Victorian Emergency Minimum Dataset (VEMD) for the 2006/2007 financial year were analysed. The presentations of Aboriginal and Torres Strait Islander and non-Aboriginal people were compared in terms of age, gender, hospital location (metropolitan and rural) and presenting condition. Aboriginal and Torres Strait Islander people were found to attend the emergency department 1.8 times more often than non-Aboriginal people. While the emergency department presentation rates of metropolitan Aboriginal and Torres Strait Islander and non-Aboriginal people were similar, rural Aboriginal and Torres Strait Islander people presented to the emergency department 2.3 times more often than non-Aboriginal people. The injuries or poisonings, respiratory conditions and mental disorders presentation rates of the Aboriginal and Torres Strait Islander and non-Aboriginal population were compared. No previous studies have assessed the accuracy of the Indigenous status and diagnosis fields in the VEMD; therefore the quality of this data is unknown.

The influence of organisational factors on the quality of hospital coding using the International Statistical Classification of Diseases and Health Related Problems, 10th Revision, Australian Modification (ICD-10-AM) was investigated using a mixed quantitative-qualitative approach. The organisational variables studied were: hospital specialty; geographical locality; structural characteristics of the coding unit; education, training and resource supports for Clinical Coders; and quality control mechanisms. Baseline data on the hospitals' coding quality, measured by the Performance Indicators for Coding Quality tool, were used as an independent index measure. No differences were found in error rates between rural and metropolitan hospitals, or general and specialist hospitals. Clinical Coder allocation to 'general' rather than 'specialist' unit coding resulted in fewer errors. Coding Managers reported that coding quality can be improved by: Coders engaging in a variety of role behaviours; improved Coder career opportunities; higher staffing levels; reduced throughput; fewer time constraints on coding outputs and associated work; and increased Coder interactions with medical staff.

This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External cause information; only 50% of hospital medical records contained sufficient information for specific code assignation for all three External cause codes, mechanism of injury, place of occurrence and activity at time of injury. Whilst all medical records contained mechanism of falls injury information, 16% contained insufficient details, indicating a deficiency in medical record documentation to underpin external cause coding. This was compounded by flaws in the ICD- 10-AM classification.

Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. Funding National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.