Failure of steril precaut during injection or immunization

This code signifies an adverse event where proper aseptic techniques were not followed during the administration of an injection or immunization. This can lead to potential complications such as infection at the injection site or systemic infection due to contamination. It indicates a breakdown in the standard protocols designed to prevent pathogen introduction during these procedures.

Use this code when documentation explicitly states that sterile precautions were breached during an injection or immunization, resulting in a complication or requiring intervention. This includes instances where non-sterile equipment was used, the skin was not properly disinfected, or other aseptic protocols were violated. It should be assigned as an external cause code to explain the circumstances leading to an injury or adverse effect.

• Always assign this code as a secondary diagnosis, never as a primary diagnosis.
• Pair this code with a primary diagnosis code indicating the specific complication that resulted from the failure of sterile precautions (e.g., cellulitis, abscess).
• Ensure the medical record clearly documents the failure of sterile precautions and its direct link to the patient's condition.