INTERNATIONAL CONFERENCE ON HARMONISATION OF TECHNICAL

REQUIREMENTS FOR REGISTRATION OF PHARMACEUTICALS FOR HUMAN

USE

ICH HARMONISED TRIPARTITE GUIDELINE

MAINTENANCE OF THE ICH GUIDELINE ON

CLINICAL SAFETY DATA MANAGEMENT :
DATA ELEMENTS FOR TRANSMISSION OF
INDIVIDUAL CASE SAFETY REPORTS
E2B(R2)

Current Step 4 version

dated 5 February 2001

This Guideline has been developed by the appropriate ICH Expert Working Group and
has been subject to consultation by the regulatory parties, in accordance with the ICH
Process. At Step 4 of the Process the final draft is recommended for adoption to the
regulatory bodies of the European Union, Japan and USA.
 E2B(R2)
Document History
New
First Codification
History Date
Codification November
2005
E2B Approval by the Steering Committee under Step 2 1 May E2B
and release for public consultation. 1996

E2B Approval by the Steering Committee under Step 4 17 July E2B

and recommendation for adoption to the three ICH 1997
regulatory bodies.

E2B(M) Approval of the first revision by the Steering 10 E2B(R1)

Committee, without further consultation, under Step November
4 and recommendation for adoption to the three ICH 2000
regulatory bodies.

Current Step 4 version

E2B(M) Approval by the Steering Committee of minor Post 5 E2B(R2)

Step 4 editorial corrections (second revision). February
2001

This guideline is currently being revised under Step 2:

E2B(R) Approval of the third revision by the Steering 12 May E2B(R3)

Committee under Step 2 and release for public 2005
consultation.

In order to facilitate the implementation of the E2B guideline, the ICH Experts have
developed a series of Q&As which can be downloaded from the ICH web site directly from the
following url : http://www.ich.org

E2B Questions & Answers History

E2B(M) Q&As Approval by the Steering Committee of the version 0.2 18 July E2B Q&As
2003

E2B(M) Q&As Approval by the Steering Committee of the version 0.3 11 Nov. 2003 E2B Q&As(R1)

E2B(M) Q&As Approval by the Steering Committee of the version 0.4 10 June E2B Q&As(R2)
2004

E2B(M) Q&As Approval by the Steering Committee of the version 0.5 18 Nov. 2004 E2B Q&As(R3)

E2B(M) Q&As Approval by the Steering Committee of the version 1.0 7 Jan. 2005 E2B Q&As(R4)

Current E2B Q&As (R5) posted on the web site

E2B(M) Q&As Approval of mistyping correction by the Steering 3 March E2B Q&As(R5)
Committee as version 1.1. 2005

ii
 MAINTENANCE OF THE ICH GUIDELINE ON
CLINICAL SAFETY DATA MANAGEMENT :
DATA ELEMENTS FOR TRANSMISSION OF
INDIVIDUAL CASE SAFETY REPORTS
ICH Harmonised Tripartite Guideline
Having been agreed by the Maintenance Contacts at the ICH Steering Committee
meeting on 10 November 2000, this guideline is recommended for
adoption to the three regulatory parties to ICH
(This document version 4.4.1 includes the Post Step 4 corrections agreed by the
Steering Committee on 5 February 2001)

TABLE OF CONTENTS

PREAMBLE ......................................................................................................................1

1. INTRODUCTION................................................................................................1
1.1 Scope of this guideline ..........................................................................................1
1.2 Background ...........................................................................................................1
1.3 Notes on format of this document ........................................................................2
1.4 Definition of data elements ..................................................................................2
1.5 Minimum information ..........................................................................................2

2. GUIDELINE: CONTENT OF THE DATA ELEMENTS ...............................3

A. Administrative and Identification Information.........................................3

A.1 Identification of the case safety report ................................................................3
A.2 Primary source(s) of information .........................................................................6
A.3 Information on sender and receiver of case safety report...................................8

B. Information on the Case ..................................................................................9

B.1 Patient characteristics..........................................................................................9
B.2 Reaction(s)/event(s).............................................................................................12
B.3 Results of tests and procedures relevant to the investigation of the patient ..14
B.4 Drug(s) information ............................................................................................15
B.5 Narrative case summary and further information ...........................................20

3. GLOSSARY ........................................................................................................20

ATTACHMENTS:

1. Unit List and Definition of Interval List....................................................21

2. Route of Administration List........................................................................22

3. Examples ...........................................................................................................23

i
 MAINTENANCE OF THE ICH GUIDELINE ON
CLINICAL SAFETY DATA MANAGEMENT :
DATA ELEMENTS FOR TRANSMISSION OF
INDIVIDUAL CASE SAFETY REPORTS

PREAMBLE
This revision provides additional information and clarification as well as some
modifications of the E2B step 4 document signed off on July 17, 1997. It incorporates
adjustments based on the successful pilot projects being conducted in the three
regions. It is recommended that the reader reviews this document as well as the M2
ICSR Message Specification document version 2.3. A new attachment 3 provides
examples of the use of ICSR identifiers.

1. INTRODUCTION

1.1 Scope of this guideline

The objectives of the working group are to standardize the data elements for
transmission of individual case safety reports by identifying, and where necessary or
advisable, by defining the data elements for the transmission of all types of individual
case safety reports, regardless of source and destination. This includes case safety
reports for both pre and post approval periods and covers both adverse drug reaction
and adverse event reports. It is not intended that this format should be used for cases
in the integrated safety summary of a marketing license application dossier. For
adverse reactions encountered in clinical trials, this format should be used only for
those subject to expedited reporting. The scope of this topic does not encompass the
definition of database structures, the design of a paper report form, quality
control/quality assurance aspects, or technical security issues.

1.2 Background
Because of national and international agreements, rules, and regulations, individual
case safety reports of adverse drug reactions and adverse events need to be
transmitted (e.g., US 21CFR314.80):
− from identified reporting sources to regulatory authorities and
pharmaceutical companies;
− between regulatory authorities;
− between pharmaceutical companies and regulatory authorities;
− within authorities or pharmaceutical companies;
− from clinical investigators, via the sponsor, to ethics committees;
− from authorities to the World Health Organization (WHO) Collaborating
Center for International Drug Monitoring.
The transmission of such individual case safety reports currently relies on paper-
based formats (e.g., yellow cards, CIOMS forms, MedWatch, …) or electronic media
(e.g. within pharmaceutical companies, or with WHO), usually by on-line access, tape
or file transfer.

1
Data Elements for Transmission of Individual Case Safety Reports

Considering the large number of potential participants in a world-wide exchange of

information, there is a need for an electronic format capable of accommodating direct
database to database transmission using message transfers.
Successful electronic transmission of information relies on the definition of common
data elements, provided in this document, and standard transmission procedures to
be specified by the ICH Electronic Standards for the Transfer of Regulatory
Information (ESTRI) Expert Working Group (M2).
This document has taken into account the documents provided by ICH sponsors, the
ENS-CARE Single Case Format, EuroSCaPE format, and the CIOMS IA proposal,
and comments received following the circulation of these papers.

1.3 Notes on format of this document

Section 2 and its subsections designated A and B contain notes that are directed
toward clarifying the nature of the data that should be provided. In addition, there
are notes to assist in defining the format that should be used to transmit the data. In
order to distinguish between these notes, the user guidances are presented in standard
type of a slightly smaller font.

If a data element has a limited set of choices, they are presented in bold Italic type.
The standard allows for this information to be transmitted in encoded format.

1.4 Definition of data elements

The format for individual case safety reports includes provisions for transmitting all
the relevant data elements useful to assess an individual adverse drug reaction or
adverse event report. The data elements are sufficiently comprehensive to cover
complex reports from most sources, different data sets, and transmission situations or
requirements; therefore, not every data element will be available for every
transmission. In many, if not most instances, a substantial number of the data
elements will not be known and therefore not included in the transmission. Where it
was deemed important, provisions for unknown/not applicable were included (e.g.,
outcome, route of administration). However, since the transmission is intended to be
electronic, it was thought to be unnecessary to include provisions to assign values of
unknown for all data elements. Different ways of including the same data have been
provided to cope with differing information contents: e.g., age information can be sent
as date of birth and date of reaction/event, age at the time of reaction/event, or patient
age group according to the available information (see section B.1.2 and the respective
user guidance). In this example, age should be provided by the most precise available
data element rather than including multiple elements of redundant data.
Structured data are strongly recommended in electronic transmission and provisions
for including information in this way have been made. However, structuring of the
data also implies the use of controlled vocabularies, which are not yet available for
some data elements. Electronic transmission of individual case safety reports should
be implemented with MedDRA where applicable. When MedDRA terms are used the
version number should be provided. MedDRA terms should be provided as either text
or code according to the regional preferences, until January 2003 when codes will be
used in all regions. In certain instances, there are provisions for the transmission of
some free text items, including a full text case summary narrative. The transmission
of other unstructured data, such as full clinical records or images is outside the scope
of this guideline.

1.5 Minimum information

2
 Data Elements for Transmission of Individual Case Safety Reports

The minimum information for the transmission of a report should include at least one
identifiable patient (section B.1), one identifiable reporter (section A.2), one
reaction/event (section B.2), and one suspect drug (section B.4). Because it is often
difficult to obtain all the information, any one of several data elements is considered
sufficient to define an identifiable patient (e.g., initials, age, sex) or an identifiable
reporter (e.g., initials, address, qualification). It is also recognized that the patient
and the reporter can be the same individual and still fulfill the minimum reporting
criteria.
In addition, to properly process the report, the following administrative information
should be provided: the sender’s (case) safety report unique identifier (A.1.0.1), the
date of receipt of the most recent information (A.1.7), the worldwide unique case
identification number (A.1.10) and the sender identifier (A.3.1.2).

2. GUIDELINE: CONTENT OF THE DATA ELEMENTS

The message content contains header information followed by E2B Data Elements.
See the M2 ICSR Message Specification for information about the header.
The data elements are divided into sections pertaining to:
A: Administrative and Identification Information
A.1 - Identification of the case safety report
A.2 - Primary source(s) of information
A.3 - Information on sender and receiver of case safety report
B: Information on the Case:
B.1 - Patient characteristics
B.2 - Reaction(s)/event(s)
B.3 - Results of tests and procedures relevant to the investigation of the patient
B.4 - Drug(s) information
B.5 - Narrative case summary and further information

A. ADMINISTRATIVE AND IDENTIFICATION INFORMATION

A.1 Identification of the case safety report

A.1.0.1 Sender’s (case) safety report unique identifier

User Guidance:
This identifier should remain constant in subsequent transmissions of the case by the same
sender. Retransmitters should replace this value with their own unique identifier. The value
should be a concatenation of “country code-company or regulator name-report number”.
Country code is the country of the primary source of the report (A.1.1). The company or
regulator name is an internationally unique abbreviation or code for the sender’s organisation.
The report number is the organisation’s international case number. Each component is
separated from the other by a hyphen. For example a report transmitted by a company to a
regulatory authority concerning a case from France would populate A.1.0.1 with “FR-
companyname-12345” where 12345 is a company’s unique case report number.

A.1.1 Identification of the country of the primary source

User Guidance:

3
Data Elements for Transmission of Individual Case Safety Reports

Generally, this item would be the only country provided. Provisions have been made to include other
countries for unusual cases concerning foreign travel and sources of manufactured material (A.1.2 and
B.4.k.2.3). See the companion document for appropriate country codes.

A.1.2 Identification of the country where the reaction/event occurred

User Guidance:
For example, this should be the country where the reaction was detected while the patient was traveling,
but the report was made by a health professional on the patient’s return.

A.1.3 Date of this transmission

User Guidance:
A full precision date should be used (i.e., day, month, year)

A.1.4 Type of report

- Spontaneous report
- Report from study
- Other
- Not available to sender (unknown)
User Guidance:
A separate category for the designation of a literature source is covered in item A.2.2 and is not
duplicated in this section which is intended to capture the type of report. If the case in the literature
arises from spontaneous observations, “type of report” should be Spontaneous report. If the case arises
from a study, “type of report” should be Report from study. If it is unclear from the literature report
whether or not the case(s) cited are spontaneous observations or arise from a study, then this item should
be Other.
Differentiation between types of studies (e.g. clinical trials or others should be given in section A.2.3.3).
The Not available to sender option allows for the transmission of information by a secondary sender
(e.g., regulatory authority) where the initial sender did not specify the type of report; it differs from
Other which indicates the sender knows the type of report but cannot fit it into the categories provided.

A.1.5 Seriousness

A.1.5.1. Serious
-Yes/no

A.1.5.2. Seriousness criteria (more than one can be chosen)

− Results in death
− Is life-threatening
− Requires inpatient hospitalization or prolongation of existing
hospitalization
− Results in persistent or significant disability/incapacity (as per
reporter's opinion)
− Is a congenital anomaly/birth defect
− Other medically important condition

4
 Data Elements for Transmission of Individual Case Safety Reports

User Guidance:
The terms life-threatening and other medically important condition are defined in the
ICH E2A guideline. All the criteria apply to the case as a whole and should not be confused
with the outcome(s) of individual reactions(s)/event(s) that are provided in section B.2.i.8. In
addition section B.2.i.3 can be used to identify the seriousness of each reaction/event in
accordance with the user guidance of the item.

A.1.6 Date report was first received from source

User Guidance:
For senders dealing with initial information, this should always be the date the information was received
from the primary source. When retransmitting information received from another regulatory agency or
another company or any other secondary source, A.1.6 is the date the retransmitter first received the
information.
A full precision date should be used (i.e., day, month, year).

A.1.7 Date of receipt of the most recent information for this report
User Guidance:
Because reports are sent at different times to multiple receivers, the initial/follow up status is dependent
upon the receiver. For this reason an item to capture follow-up status is not included. However, the date
of receipt of the most recent information taken together with the “sender identifier” (A.3.1.2) and
“sender’s (case) report unique identifier” (A.1.0.1) provide a mechanism for each receiver to identify
whether the report being transmitted is an initial or follow-up report. For this reason these items are
considered critical for each transmission.
A full precision date should be used (i.e., day, month, year).

A.1.8 Additional available documents held by sender

A.1.8.1 Are additional documents available?

- yes/no

A.1.8.2 List of documents held by sender

User Guidance:
The documents received from the primary source (e.g., clinical records, hospital records,
autopsy reports) should be listed. It is recognized that these documents may not be obtainable
in many instances.

A.1.9 Does this case fulfill the local criteria for an expedited report?
- yes/no
User Guidance:
The definition of expedited is dependent upon the local regulatory requirements. This item should be
used by the sender to indicate if the case fufills the local expedited requirements. When the countries of
origin and destination of the transmission differ, the receiver should be aware that the information might
not be applicable to their regulatory requirements.

A.1.10 Worldwide unique case identification number.

User Guidance:
Only A.1.10.1 or A.1.10.2 should be used. No case should ever have more than one of these items
completed. The contents of whichever item is used should remain unchanged for any transmissions
subsequent to the original transmission. When a regulator is the initial sender A.1.10.1 should be used.
When an entity other than a regulator is the initial sender, A.1.10.2 should be used. When a sender has
not previously received a valid E2B/M2 report electronically, the identifiers (content and format) in
A.1.0.1 and A.1.10.1 or A.1.10.2 should be identical. Retransmitters should use their own sender’s (case)
safety report unique identifier (A.1.0.1), but not change A.1.10.1 or A.1.10.2. See examples in attachment
3.

5
Data Elements for Transmission of Individual Case Safety Reports

A.1.10.1 Regulatory authority’s case report number

A.1.10.2 Other sender’s case report number

A.1.11 Other case identifiers in previous transmissions

-yes
User Guidance:
This item should be completed only if the answer is yes.

A.1.11.1 Source(s) of the case identifier (e.g., name of the company,

name of regulatory agency)
User Guidance:
This repeatable item should be used in conjunction with A.1.11.2 to provide all other case
identifiers electronically transmitted, perhaps by multiple other senders. If the case has been
received from another sender all other case identifiers included in A.1.11.1 and A.1.11.2 should
be present. In addition the identifier of the previous sender (A.1.0.1) should be included here by
the retransmitter. See examples in attachment 3.

A.1.11.2 Case identifier(s)

A.1.12 Identification number of the report which is linked to this report

(repeat as necessary)
User Guidance:
This section should be used to identify reports or cases that warrant being evaluated together. This
includes, but is not limited to, a mother-child pair where both had reactions/events, siblings with
common exposure, several reports involving the same patient (e.g., a report sent via paper without a
valid E2B/M2 electronic report identifier), several similar reports from same reporter (cluster). This item
can also be used when a sender decides to create two or more ICSRs to provide individualised
information on two or more suspect drugs in a single case (see B.2.i.7 and B.4.k.13). See examples in
attachment 3.

A.1.13 Report nullification

-yes
User Guidance:
This item should be used to indicate that a previously transmitted report should be considered
completely void (nullified), for example when the whole case was found to be erroneous. It is essential to
use the same case report number previously submitted.

A.1.13.1 Reason for nullification

A.1.14 Was the case medically confirmed, if not initially from a health
professional?
-yes/no
User Guidance:
This section should be completed if the primary source of information was a lawyer, consumer, or other
non-health professional. It is important because of regional differences in regulations concerning lay
reports.

A.2 Primary source(s) of information

The primary source(s) of the information is a person who reports the facts. This
should be distinguished from senders (secondary sources) who are transmitting the
information, (e.g., industry to regulatory authority).

6
 Data Elements for Transmission of Individual Case Safety Reports

Any or all of the three subsections (A.2.1, A.2.2., A.2.3) can be used. In the case of a
published study or published individual case, the reporter would be the investigator
or first author, and details on publication and trial type should also be provided.

A.2.1 Primary source(s) (repeat as necessary)

A.2.1.1 Reporter identifier (name or initials)

User Guidance:
The identification of the reporter may be prohibited by certain national confidentiality laws or
directives. The information should be provided when it is in conformance with the regional
confidentiality requirements and this guidance applies to all the subsections of A.2.1.
Notwithstanding the above, at least one subsection should be completed to ensure there is an
identifiable reporter. If only the name of the reporter is known and providing this name is
prohibited because of confidentiality requirements, initials can be used.

A.2.1.2 Reporter’s address

User Guidance:
See the companion document for format specifications.

A.2.1.3 Country
User Guidance:
See the companion document for format specifications.

A.2.1.4 Qualification
− Physician
− Pharmacist
− Other health professional
− Lawyer
− Consumer or other non health professional
User Guidance:
In some regions, consumer and lawyer reports should be transmitted only when there is
medical confirmation.

A.2.2 Literature reference(s)

User Guidance:
References are provided in the Vancouver Convention (known as "Vancouver style") as developed by the
International Committee of Medical Journal Editors. The standard format as well as those for special
situations can be found in the following reference which is in the Vancouver style. International
Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical
journals. N Engl J Med 1997; 336:309-15.

A.2.3 Study identification

A.2.3.1 Study name

A.2.3.2 Sponsor study number

User Guidance:
This section would be completed only if the sender is the study sponsor or has been informed of
the study number by the sponsor.

7
Data Elements for Transmission of Individual Case Safety Reports

A.2.3.3 Study type in which the reaction(s)/event(s) were observed

− Clinical trials
− Individual patient use; (e.g.”compassionate use” or named patient
basis)
− Other studies (e.g., pharmacoepidemiology, pharmacoeconomics, intensive
monitoring, PMS, etc.)

A.3 Information on sender and receiver of case safety report

A.3.1 Sender

A.3.1.1 Type
− Pharmaceutical company
− Regulatory authority
− Health professional
− Regional pharmacovigilance center
− WHO collaborating center for international drug monitoring
− Other (e.g. distributor, study sponsor, or contract research organization)
User Guidance:
In this context, a pharmaceutical company includes biotechnology companies and other
manufacturers required to submit individual case safety reports.

A.3.1.2 Sender identifier

User Guidance:
Identifies the sender, (e.g., company name or regulatory authority name). This item should
always be completed.

A.3.1.3 Person responsible for sending the report

User Guidance:
Name of person in the company or agency who is responsible for the authorization of report
dissemination. This would usually be the same person who signs the covering memo for paper
submissions. The inclusion of the name of this person in the transmission may be subject to
national or international regulations.

A.3.1.4 Sender’s address, fax, telephone and E-mail address

A.3.2 Receiver
User Guidance:
See the user guidance concerning the sender (A.3.1).

A.3.2.1 Type
− Pharmaceutical company
− Regulatory authority
− Regional pharmacovigilance center
− WHO collaborating center for international drug monitoring
− Other (e.g., a company affiliate or a partner)

8
 Data Elements for Transmission of Individual Case Safety Reports

A.3.2.2 Receiver identifier (see glossary)

A.3.2.3 Receiver’s address, fax, telephone and E-mail address

B. INFORMATION ON THE CASE

B.1 Patient characteristics

User Guidance:
In cases where a fetus or suckling infant sustains an adverse reaction/event, information on both the
parent and the child/fetus should be provided. Reports of these cases are referred to as parent-child/fetus
report. Several general principles should be used for filing these reports. If there has been no
reaction/event affecting the child/fetus the parent-child/fetus report does not apply. For those cases
describing fetal demise or early spontaneous abortion, only a parent report is applicable. If both the
parent and the child/fetus sustain adverse events, two reports should be provided but they should be
linked by using sections A.1.12 in each of the reports. When only the child/fetus has an adverse
reaction/event (other than early spontaneous abortion/fetal demise) the information provided in this
section applies to the child/fetus, and characteristics concerning the parent who was the source of
exposure to the drug should be provided in section B.1.10.

B.1.1 Patient (name or initials)

User Guidance:
The identification of the patient may be prohibited by certain national confidentiality laws or directives.
The information should be provided when it is in conformance with the confidentiality requirements.
This also applies to medical record number(s) (B.1.1.1).

B.1.1.1 Patient medical record number(s) and the source(s) of the

record number (if allowable)
User Guidance:
Record numbers can include the health professional record(s) number(s), hospital record(s)
number(s), or patient/subject identification number in a study. The source of the number
should be specified to ensure the possibility of retrieval when possible and desirable.

B.1.2 Age information

User Guidance:
Only one of the elements describing age should be used. The choice should be based upon the most
precise information available.

B.1.2.1 Date of birth

User Guidance:
A full precision date should be used (i.e., day, month, year). If the full date of birth is not
known an approximate age can be used in section B.1.2.2.

B.1.2.2 Age at time of onset of reaction/event

User Guidance:
If several reactions/events are in the report, the age at the time of the first reaction/event
should be used. For fetal reaction(s)/event(s) the next item B.1.2.2.1 “Gestation period when
reaction/event was observed in the fetus” should be used.
When providing the age in decades, please note that, for example, the 7th decade refers to a
person in their 60’s.
See the companion document for format specifications.

9
Data Elements for Transmission of Individual Case Safety Reports

B.1.2.2.1 Gestation period when reaction/event was observed in the fetus

User Guidance:
The gestation period at the time of exposure is captured in section B.4.k.10.
See the companion document for format specifications.

B.1.2.3 Patient age group (as per reporter)

− Neonate
− Infant
− Child
− Adolescent
− Adult
− Elderly
User Guidance:
The terms are not defined in this document and are intended to be used as they were reported by the
primary source. This section should be completed only when the age is not provided more specifically in
sections B.1.2.1 or B.1.2.2.

B.1.3 Weight (kg)

User Guidance:
The weight at the time of the event/reaction.

B.1.4 Height (cm)

B.1.5 Sex
User guidance:
See the companion document for format specifications.

B.1.6 Last menstrual period date

User guidance:
Imprecise dates can be included, (i.e., month, and year or year only). See the companion document for
format specifications.

B.1.7 Relevant medical history and concurrent conditions (not including

reaction/event)

B.1.7.1 Structured information on relevant medical history

including onset and resolution date as well as relevant
comments. (repeat as necessary)
Disease / surgical procedure / etc. Start date Continuing End date Comments
Y/N/U

User Guidance:
Medical judgment should be exercised in completing this section. Information pertinent to
understanding the case is desired such as diseases, conditions such as pregnancy, surgical procedures,
psychological trauma, etc. Each of the items in the table can be repeated as appropriate. If precise dates
are not known and a text description aids in understanding the medical history, or if concise additional

10
 Data Elements for Transmission of Individual Case Safety Reports

information is helpful in showing the relevance of the past medical history, this information can be
included in the Comments column.
If applicable, MedDRA terms should be used in the main descriptive column for disease/surgical
procedure/etc. Imprecise dates can be used for both start and end dates. See the companion document
for format specifications for the continuing column.

B.1.7.2 Text for relevant medical history and concurrent conditions

(not including reaction/event)
User Guidance:
If structured information is not available in the sender’s database this item should be used.
Otherwise, it is preferable to send structured data in segment B.1.7.1.

B.1.8 Relevant past drug history (repeat the line as necessary)

Name of drug Start date End date Indication Reactions
as reported

User Guidance:
This segment concerns drugs previously taken, but not those taken concomitantly or drugs which may
have potentially been involved in the current reaction(s)/event(s). Information concerning concomitant
and other suspect drugs should be included in section B4. The information provided here can also
include previous experience with similar drugs. Medical judgment should be exercised in completing this
section. When completing the item concerning the name of the drug it is important to use the words
provided by the primary source. Trade name, generic name or class of drug can be used. The term
"none" should be used when appropriate, (e.g., when there is no previous exposure to the drug or vaccine,
or no previous reaction following exposure).
If applicable, MedDRA terms should be used in the Indication and Reaction columns. Imprecise dates can
be used for both start and end dates.

B.1.9 In case of death

B.1.9.1 Date of death

User Guidance:
An imprecise date can be used. See the companion document for format specifications.

B.1.9.2 Reported cause(s) of death (repeat as necessary)

User Guidance:
MedDRA if applicable

B.1.9.3 Was autopsy done?

Yes/No/Unknown

B.1.9.4 Autopsy-determined cause(s) of death (repeat as necessary)

User Guidance:
MedDRA if applicable

B.1.10 For a parent-child/fetus report, information concerning the parent

User Guidance:
This section should be used in the case of a parent-child/fetus report where the parent had no
reaction/event. See user guidance for section B.1. Guidance regarding confidentiality is provided in
B.1.1, and should be considered before providing the parent identification. For the subsections B.1.10.4

11
Data Elements for Transmission of Individual Case Safety Reports

through B.1.10.8, the guidances provided for B.1.3 through B.1.5 and B.1.7 through B.1.8 should be
reviewed.

B.1.10.1 Parent identification

B.1.10.2 Parent age information

User Guidance:
The date of birth should be used if the precise birthday is known; otherwise the age should be
used.

B.1.10.2.1 Date of birth of parent

User Guidance:
A full precision date should be used. See the companion document for format specifications.

B.1.10.2.2 Age of parent

B.1.10.3 Last menstrual period date

User Guidance:
A full precision date should be used. See the companion document for format specifications.
If a precise date is not available, the gestation period at time of exposure in B.4.k.10 should be
completed.

B.1.10.4 Weight (kg) of parent

B.1.10.5 Height (cm) of parent

B.1.10.6 Sex of parent

B.1.10.7 Relevant medical history and concurrent conditions of

parent (not including reaction/event)

B.1.10.7.1 Structured information (parent)

Disease / surgical procedure/ etc. Start date Continuing End date Comments
Y/N/U

B.1.10.7.2 Text for relevant medical history and concurrent conditions of

parent (not including reaction/event)

B.1.10.8 Relevant past drug history of parent

Name of drug Start date End date Indication Reactions (if any and
as reported known)

B.2 Reaction(s)/event(s)
User Guidance:
The designation of “i” in this section indicates that each item is repeatable and that it carries an
appropriate correspondence to the same “i” in all subsections. A separate block (i) should be used for
each reaction/event term. For example, if two reactions are observed, the first reaction would be

12
 Data Elements for Transmission of Individual Case Safety Reports

described in items B.2.1.0 through B.2.1.8, and the other reaction would be described in items B.2.2.0
through B.2.2.8. The reaction/event specified in the first iteration should be the one used in assessing the
intervals in B.4.k.13.

B.2.i.0 Reaction/event as reported by the primary source

User Guidance:
The original reporter's words and/or short phrases used to describe the reaction/event. (The
original reporter's words and/or short phrases used to describe reaction/event can also be
included in the narrative B.5.1).

B.2.i.1 Reaction/event in MedDRA terminology (Lowest Level Term)

User Guidance:
Only the MedDRA Lowest Level Term (LLT) most closely corresponding to the reaction/event
as reported by the primary source should be provided.. In the exceptional circumstance when a
MedDRA term cannot be found the sender should use good clinical judgment to complete this
item with the best MedDRA approximation (see MedDRA™ TERM SELECTION:POINTS TO
CONSIDER). MedDRA terms should be provided as either text or code according to the
regional preferences until January 2003 when codes should be used in all regions. For
international transmissions, English is the generally accepted language.

B.2.i.2 Reaction/event MedDRA term (Preferred Term)

User Guidance:
The term can be a sign, symptom or diagnosis. This also applies to the other items of structured
data such as indication, diseases in past medical history, etc. MedDRA terms are to be provided
as either text or code according to the regional preferences until January 2003 when codes
should be used in all regions. For international transmissions, English is the generally
accepted language.

B.2.i.3 Term highlighted by the reporter

1= Yes, highlighted by the reporter, NOT serious
2= No, not highlighted by the reporter, NOT serious
3= Yes, highlighted by the reporter, SERIOUS
4= No, not highlighted by the reporter, SERIOUS
User Guidance:
A highlighted term is a reaction/event that the primary source indicated was a major concern
or reason for reporting the case. If the information is not explicitly provided by the initial
reporter the term should not be considered a highlighted term. The seriousness of the
reaction/event should be based on the ICH E2A criteria.

B.2.i.4 Date of start of reaction/event

User Guidance:
See the companion document for format specifications.

B.2.i.5 Date of end of reaction/event

B.2.i.6 Duration of reaction/event

User Guidance:
This section can usually be computed from start/end of reaction/event. Both dates and duration
may be useful (e.g., for a reaction/event of short duration such as anaphylaxis or arrhythmia).
Imprecise dates can be used. See the companion document for format specifications.

B.2.i.7 Time intervals between suspect drug administration and

start of reaction/event

13
Data Elements for Transmission of Individual Case Safety Reports

User Guidance:
The major uses of intervals are to cover circumstances where both the dates are known but the
interval is very short (e.g., minutes, such as in anaphylaxis), and when only imprecise dates are
known but more information concerning the interval is known. Dates if available should
always be transmitted in the appropriate fields rather than intervals.
B.2.i.7 captures the interval between each reaction/event and only the first iteration of the drug
in B.4.k. If there is more than one suspect drug and it is deemed critical, more than one ICSR
can be used to provide all the intervals between each reaction/event and all suspect drugs. In
this circumstance it is advisable to indicate the reports are linked in A.1.12. The complexity of
the intervals highlights the desirability of providing dates. See the companion document for
format specifications.

B.2.i.7.1 Time interval between beginning of suspect drug administration and

start of reaction/event

B.2.i.7.2 Time interval between last dose and start of reaction/event

B.2.i.8 Outcome of reaction/event at the time of last observation

− recovered/resolved
− recovering/resolving
− not recovered/not resolved
− recovered/resolved with sequelae
− fatal
− unknown
User Guidance:
In case of irreversible congenital anomalies the choice, not recovered/not resolved should be
used.
Fatal should be used when death is possibly related to the reaction/event. Considering the
difficulty of deciding between "reaction/event caused death" and "reaction/event contributed
significantly to death", both were grouped in a single category. Where the death is unrelated,
according to both the reporter and the sender, to the reaction/event, death should not be
selected here, but should be reported only under section B.1.9.

B.3 Results of tests and procedures relevant to the investigation of the

patient
User Guidance:
This section should capture the tests and procedures performed to diagnose or confirm the
reaction/event, including those tests done to investigate (exclude) a non-drug cause, (e.g.,
serologic tests for infectious hepatitis in suspected drug-induced hepatitis). Both positive and
negative results should be reported. While structured information is preferable, provisions
have been made to transmit the information as free text in B.3.2.

14
 Data Elements for Transmission of Individual Case Safety Reports

B.3.1 Structured information (repeat as necessary)

Date Test Result Unit Normal low range Normal high range More information
available (Y/N)

User Guidance:
Imprecise dates can be used, units and normal ranges should be in free text unless covered by a
controlled vocabulary. The column entitled "more information available" accepts only yes or no (see the
companion document for the appropriate format). If results and units cannot be split, use B.3.2. More
than one test can be included in B.3.2.

B.3.2 Results of tests and procedures relevant to the investigation

B.4 Drug(s) information

User Guidance:
This section covers both suspect drugs and concomitant medications including biologicals. In addition,
the section can be used to identify drugs thought to have an interaction. For each drug, the
characterization of the drug role (B.4.k.1) is that indicated by the primary reporter, (i.e., the original
source of the information). The designation of ”k” in this section indicates that each item is repeatable
and that it carries an appropriate correspondence to the same “k” in all subsections. A separate block (k)
should be used for each drug. The drug specified in the first iteration should be the one used in assessing
the intervals in item B.2.i.7. Drugs used to treat the reaction/event should not be included here.

B.4.k.1 Characterization of drug role

Suspect/Concomitant/Interacting
User Guidance:
Characterization of the drug as provided by primary reporter. All spontaneous reports should
have at least one suspect drug (see Section 1.5). If the reporter indicates a suspected
interaction, “interacting” should be selected. All interacting drugs are considered to be suspect
drugs.

B.4.k.2 Drug identification

User Guidance:
Drug substance name and/or proprietary medicinal product name should be provided as it was
reported. In case of investigational drugs only a code may be known and provided. If more than
one active substance is specified, each should be included as a separate drug in item B.4.k.2.2.
and repeating the entire drug block (reiteration of “k”) rather than as a repeating item
B.4.k.2.2. An exception can be made when a proprietary medicinal product is provided in
B.4.k.2.1, in which case the active substances can be specified as a repeating item in B.4.k.2.2.

B.4.k.2.1 Proprietary medicinal product name

User Guidance:
The name should be that used by the reporter. It is recognized that a single product may have
different proprietary names in different countries, even when produced by a single
manufacturer.

B.4.k.2.2 Active substance name(s)

User Guidance:
The INN(s) or drug substance name(s) or drug identification code(s) should be provided if no
name exists. For combination products, each active ingredient should be specified. This
information, as well as that requested for Proprietary medicinal product name (B.4.k.2.1) may
not be known for concomitant or interacting drugs when the sender is a pharmaceutical
company. In the case of blinded trials, in the exceptional circumstance when the blind has not
been broken, the word "blinded" should precede the names of the drugs included in the study.
Placebo can be included as a drug.

15
Data Elements for Transmission of Individual Case Safety Reports

B.4.k.2.3 Identification of the country where the drug was obtained.

User Guidance:
See the companion document for the appropriate codes and format.

B.4.k.3 Batch/lot number

User Guidance:
This information is particularly important for vaccines and biologicals. The section allows for
multiple batch/lot numbers, each separated by a delimiter defined by the transmission
standard chosen. The most specific information available should be provided. For expiration
date and other related information, see additional information on drug (B.4.k.19).

B.4.k.4 Holder and authorization/application number of drug

User Guidance:
If relevant and known, the name of the holder should be provided with the authorization
number in the country where the drug was obtained when the case report is sent to that
country. These items apply to both applications and authorizations. Pharmaceutical companies
provide this information for their own suspect drug(s).

B.4.k.4.1 Authorization/Application Number

B.4.k.4.2 Country of authorization/application

User Guidance:
See the companion document for the appropriate codes and format.

B.4.k.4.3 Name of holder/applicant

B.4.k.5 Structured Dosage Information

(e.g., 2 mg three times a day for five days)
B.4.k.5.1 dose (number) 2
B.4.k.5.2 dose (unit) mg
B.4.k.5.3 number of separate dosages 3
B.4.k.5.4 number of units in the interval 1
B.4.k.5.5 definition of the interval unit day
B.4.k.5.6 cumulative dose to first reaction (number) 30
B.4.k.5.7 cumulative dose to first reaction (unit) mg
User Guidance:
Please note the above side-by-side illustration of how the structured dosage is provided. For
the more complex example of 5mg (in one dose) every other day for 30 days, subsections
B.4.k.5.1 through B.4.k.5.7 would be 5, mg, 1, 2, day, 75, mg, respectively. In the same way, 50
mg daily for 2 days would be 50, mg, 1, 1, day, 100, mg. For prolonged chronic therapy, the
sender should consider the need to complete the cumulative dose sections.
The cumulative dose provided is the total dose administered until the first sign, symptom or
reaction.
In the case of a parent-child/fetus report, the dosage section applies to the parental dose.
For dosage regimen that involve more than one dosage form and/or changes in dosage, the
information should be provided in section B.4.k.6 as text. Alternatively, the sender can provide
more than one iteration (k) for the same drug. Categories for "dose unit" and for "definition of
the interval" are described in attachment 1.

B.4.k.6 Dosage text

16
 Data Elements for Transmission of Individual Case Safety Reports

User Guidance:
This item should be used in cases where provision of structured dosage information is not
possible.

B.4.k.7 Pharmaceutical form (Dosage form)

User Guidance:
e.g., tablets, capsules, syrup. Free text until a controlled vocabulary is available.

B.4.k.8 Route of administration

User Guidance:
See suggested vocabulary in the route of administration list in Attachment 2. For a parent-
child/fetus report this indicates the route of administration of a drug given to the child/fetus.
This is usually an indirect exposure such as transmammary but can include more usual routes
of administration for other drugs given to the child. The parent’s route of administration should
be provided in B.4.k.9.

B.4.k.9 Parent route of administration (in case of a parent

child/fetus report)
User Guidance:
This section should be used in a parent-child/fetus report and linked parent reports to indicate
the route of administration to the parent.

B.4.k.10 Gestation period at time of exposure

User Guidance:
Use the gestational age at the time of the earliest exposure
Gestation period at time of exposure should be expressed by providing both a number and
designation of units of days, weeks, months or trimester. See the companion document for
format specifications.

B.4.k.11 Indication for use in the case

User Guidance:
The indication as reported. For multiple indications for the same drug, repeat the entire B.4.k
block specifying the same drug for each indication. MedDRA terms should be provided as either
text or code according to regional preferences until January 2003 when codes should be used in
all regions. B.4.k.19 can be used to provide indications in other terminologies.

B.4.k.12 Date of start of drug

B.4.k.13 Time intervals between drug administration and start of

reaction/event
User Guidance:
The major uses of intervals are to cover circumstances where both the dates are known but the
interval is very short (e.g., minutes, such as in anaphylaxis), and when only imprecise dates are
known but more information concerning the interval is known. Dates if available should
always be transmitted in the appropriate items, rather than intervals.
B.4.k.13 captures the interval between each drug and only the reaction/event in the first
iteration of B.2.i. If there is more than one reaction/event and it is deemed necessary, more
than one ICSR can be used to provide all the intervals between each suspect drug and all
reactions/events. In this circumstance it is advisable to indicate the reports are linked in
A.1.12. The complexity of the intervals highlights the desirability of providing dates. See the
companion document for format specifications.

17
Data Elements for Transmission of Individual Case Safety Reports

B.4.k.13.1 Time interval between beginning of drug administration and

start of reaction/event

B.4.k.13.2 Time interval between last dose of drug and start of

reaction/event

B.4.k.14 Date of last administration

User Guidance
For ongoing drug administration after the onset of the reaction/event, this item should be blank
and Action(s) taken with drug (B.4.k.16) should be used.

B.4.k.15 Duration of drug administration

User Guidance:
This item should be used if exact dates of drug administration are not available at the time of
the report, but there is information concerning the duration of drug administration. The
information requested is the overall duration of drug administration and covers intermittent
administration. See the companion document for the appropriate format.

B.4.k.16 Action(s) taken with drug

− Drug withdrawn
− Dose reduced
− Dose increased
− Dose not changed
− Unknown
− Not applicable
User Guidance:
These data, taken together with the outcome of the reaction (B.2.i.8), provide the information
concerning dechallenge. “Not applicable” should be used in circumstances such as if the patient
died or the treatment had been completed prior to reaction/event.

B.4.k.17 Effect of rechallenge (or re-exposure), for suspect drug(s)

only

B.4.k.17.1 Did reaction recur on readministration?

-yes/no/unknown
User Guidance:
Unknown indicates that a rechallenge was done but it is not known if the event recurred. This
segment should not be completed if it is unknown whether a rechallenge was done.

B.4.k.17.2 If yes to item B.4.k.17.1, which reaction(s)/event(s) recurred?

User Guidance:
Use MedDRA terms

B.4.k.18 Relatedness of drug to reaction(s)/event(s) (repeat B.4.k.18.1

through B.4.k.18.4 as necessary)
User Guidance:
This section provides the means to transmit the degree of suspected relatedness of each drug to
the reaction(s)/event(s). The repeating items could also be used to provide the assessment of
relatedness by different sources or methods of assessment. For the purpose of reporting, there
is an implied suspicion of causality for spontaneous reports. It is recognized that information

18
 Data Elements for Transmission of Individual Case Safety Reports

concerning the relatedness, especially for spontaneous reports, is often subjective and may not
be available.
• The following example illustrates the extensive functionality contained in this section.
• Assume a patient being treated with two medications: Drug A and Drug B.
• Assume the patient has had three adverse events: Event 1, Event 2, and Event 3
• The reporter provided assessment of causality for events 1 and 2 for both Drug A and Drug
B, but not for either drug concerning event 3. The reporter’s assessment of causality is
based on overall impression which the sender codes as “global introspection”.
• The sender applies two methods of causality assessment, one with an algorithm (coded
algorithm) and the other a bayesian analysis which provides a decimal probability (coded
Bardi) but it does so only for the drug it manufactures (in this case Drug A).
• From the above there are 4 sets of data for the reporter (2drugsX2eventsX1method of
assessment) and 6 sets for the sender (1drugX3eventsX2methods of assessment) for a total
10 sets of data.
• The appropriate item with the information is B.4.k.18 (and its four subfields 1-4). In this
example k is replaced by Drug A and Drug B respectively. Please note the subfields 1-4 are
repeatable. Thus:

B.4.k.18.1 B.4.k.18.2 B.4.k.18.3 B.4.k.18.4

k(1) = DRUG A
event1 reporter global introspection related
event1 company algorithm possibly related
event1 company Bardi 0.76
event2 reporter global introspection not related
event2 company algorithm possibly related
event2 company Bardi 0.48
event3 company algorithm unlikely related
event3 company Bardi 0.22

k(2) = DRUG B
event1 reporter global introspection not related
event2 reporter global introspection not related

The order of the rows is not important since each one represents a complete set, however the E2B
message and M2 specifications state that all assessments for Drug A (k=1) appear before Drug B (k=2).
For subsection B.4.k.18.1 MedDRA terms should be used. Subsections B.4.k.18.2 through B.4.k.18.4 do
not require a controlled vocabulary.

B.4.k.18.1 Reaction assessed

User Guidance:
Generally the reactions assessed are ordered from the most important or the most serious to
the least important.

B.4.k.18.2 Source of assessment (e.g., initial reporter, investigator,

regulatory agency, company).

19
Data Elements for Transmission of Individual Case Safety Reports

B.4.k.18.3 Method of assessment (e.g., global introspection, algorithm,

Bayesian calculation).

B.4.k.18.4 Result

B.4.k.19 Additional information on drug

User Guidance:
This should be used to specify any additional information pertinent to the case that is not
covered by above sections. (e.g., beyond expiration date, batch and lot tested and found to be
within specifications). This item can also be used to provide additional information concerning
the indication for the drug. Regional requirements may involve the use of a controlled
vocabulary to provide the additional information concerning indication.

B.5 Narrative case summary and further information

B.5.1 Case narrative including clinical course, therapeutic measures,

outcome and additional relevant information.
User Guidance:
Focused, factual and clear description of the case should be given, including the words or short phrases
used by the reporter.

B.5.2 Reporter's comments

User Guidance:
This item should be used to include the reporter's comments on the diagnosis, causality assessment or
other issues considered relevant.

B.5.3 Sender's diagnosis/syndrome and/or reclassification of reaction/event

User Guidance:
This section provides the sender with an opportunity to combine signs and symptoms that were reported
into a succinct diagnosis and the reasoning would be included in section B.5.4. MedDRA terminology.

B.5.4 Sender's comments

User Guidance:
This section provides information concerning the sender's assessment of the case and can be used to
describe disagreement with, and/or alternatives to the diagnoses given by the initial reporter.

3. GLOSSARY
Parent-child/fetus report: Report in which the administration of medicines to a
parent results in a suspected reaction/event in a child/fetus.
Receiver: The intended recipient of the transmission.
Reporter: Reporter is the primary source of the information, (i.e., a person who
initially reports the facts). This should be distinguished from the sender of the
message, though the reporter could also be a sender.
Sender: The person or entity creating the message for transmission. Although the
reporter and sender may be the same person, the function of the sender should not be
confused with that of the reporter.

20
 Data Elements for Transmission of Individual Case Safety Reports

ATTACHMENT 1

Unit List
Mass Volume
kg kilogram(s) l litre(s)
g gram(s) ml millilitre(s)
mg milligram(s) µl microlitre(s)
µg microgram(s)
ng nanogram(s)
pg picogram(s)
mg/kg milligram(s)/kilogram
µg/kg microgram(s)/kilogram
mg/m2 milligram(s)/sq. meter
µg/m2 microgram(s)/ sq. meter

Radioactivity Other
Bq becquerel(s) mol mole(s)
GBq gigabecquerel(s) mmol millimole(s)
MBq megabecquerel(s) µmol micromole(s)
Kbq kilobecquerel(s) iu international unit(s)
Ci curie(s) kiu iu(1000s)
mCi millicurie(s) Miu iu(1,000,000s)
µCi microcurie(s) iu/kg iu/kilogram
nCi nanocurie(s) mEq milliequivalent(s)
% percent
gtt drop(s)
DF dosage form

User Guidance:
This is the suggested list of units. When using other units, transformation is recommended if possible.
Otherwise the free text field should be used.

Definition of Interval List

Minutes
Hours
Days
Weeks
Months
Years
Cyclical
As necessary
Total

21
Data Elements for Transmission of Individual Case Safety Reports

ATTACHMENT 2

Route of Administration List

Auricular (otic)
Buccal Intrasynovial
Cutaneous Intratumor
Dental Intrathecal
Endocervical Intrathoracic
Endosinusial Intratracheal
Endotracheal Intravenous bolus
Epidural Intravenous drip
Extra-amniotic Intravenous (not otherwise specified)
Hemodialysis Intravesical
Intra corpus cavernosum Iontophoresis
Intra-amniotic Nasal
Intra-arterial Occlusive dressing technique
Intra-articular Ophthalmic
Intra-uterine Oral
Intracardiac Oropharingeal
Intracavernous Other
Intracerebral Parenteral
Intracervical Periarticular
Intracisternal Perineural
Intracorneal Rectal
Intracoronary Respiratory (inhalation)
Intradermal Retrobulbar
Intradiscal (intraspinal) Subconjunctival
Intrahepatic Subcutaneous
Intralesional Subdermal
Intralymphatic Sublingual
Intramedullar (bone marrow) Topical
Intrameningeal Transdermal
Intramuscular Transmammary
Intraocular Transplacental
Intrapericardial Unknown
Intraperitoneal Urethral
Intrapleural Vaginal

22
 Data Elements for Transmission of Individual Case Safety Reports

ATTACHMENT 3
Examples of how to populate fields relevant to identifying cases and their reports
The figure provides an example of how one would populate the fields relevant to identifying
cases and their reports. Patient XX suffers three separate adverse events (AE1, AE2, AE3)
spaced over a time period.

Example of a simple single report from a company to a regulator

Hospital X reports AE1 to Company K who then in turn sends ICSR1 to Regulator.
Population of relevant fields for this case is illustrated in the first row of the table. Company
K populates A.1.0.1 with Company K’s (case) safety report unique identifier “JP-K-001”.
Company K populates A.1.10.2 with “JP-K-001” because company K is the initial sender of the
report. Because there has not been a previous E2B/M2 electronic report, the identifiers in
A.1.0.1 and A.1.10.2 are the same.

Example of company to company to company to regulator transmission

Hospital X reports AE1 to Company B who then in turn sends ICSR2 to Company C.
Population of relevant fields for this case is illustrated in the second row of the table.
Company B populates A.1.0.1 with Company B’s (case) safety report unique identifier “JP-B-
001”. Company B populates A.1.10.2 with “JP-B-001” because company B considers itself the
initial sender of the report because it is unaware that Company K also sent an ICSR for this
case.
Company C sends ICSR3 to Company D. The third row of the table indicates how Company C
populates the relevant fields. Company C populates A.1.0.1 with “JP-C-001”. Company C
populates A.1.10.2 with “JP-B-001”, leaving the field unchanged from the way Company B
populated it. In addition, Company C populates A.1.11.1 (Source of the case identifier) with
the name of company B, “B”. A.1.11.2 is populated with Case Identifier in the Previous
Transmission by Company B “JP-B-001”.
Company D sends ICSR4 to Regulator. The fourth row of the table indicates how Company D
populates the relevant fields. Company D populates A.1.0.1 with “JP-D-001”. Company D
retains in fields A.1.10.2, A.1.11.1, and A.1.11.2 the information populated by Company C, and
Company D adds to the retained information in repeatable field A.1.11.1 “C” to represent that
Company C is another source of the case identifier, and Company D adds in field A.1.11.2 “JP-
C-001” to represent Company C’s case identifier from the previous transmission.

Example of a simple single report with follow-up from a company to a regulator

Hospital X reports AE1 to Company E who then in turn sends ICSR5 to Regulator. Population
of relevant fields for this case is illustrated in the fifth row of the table. Company E populates
A.1.0.1 with Company E’s (case) safety report unique identifier “JP-E-001”. Company E
populates A.1.10.2 with “JP-E-001” because company E is the initial sender of the report.
Because to Company E’s knowledge, there has not been a previous E2B/M2 electronic report,
the identifiers in A.1.0.1 and A.1.10.2 are the same.
ICSR6 represents Hospital X’s follow-up information about AE1 to Company E. Company E
submits follow-up to ICSR5 to the regulator. The relevant fields, A.1.0.1 and A.1.10.2, are
populated the same as for ICSR5. ICSR6, a follow-up report, is differentiated from ICSR5 by
A.1.7, Date of Receipt of the Most Recent Information for this Report.

Example of Linking Two Separate Adverse Events Affecting the Same Patient
Patient XX later suffers a separate adverse event, AE2. Hospital X reports AE2 to Company K
who then in turn sends ICSR7 to Regulator. Population of relevant fields for this new case is
illustrated in the seventh row of the table. Company K populates A.1.0.1 with Company K’s
(case) safety report unique identifier “JP-K-002”. Company K assigns a new (case) safety

23
Data Elements for Transmission of Individual Case Safety Reports

report unique identifier “JP-K-002” because “JP-K-001”, as described above, represent a

separate adverse event. Company K populates A.1.10.2 with “JP-K-002” because company K
is the initial sender of the report. Because there has not been a previous E2B/M2 electronic
report, the identifiers in A.1.0.1 and A.1.10.2 are the same. The previous report from
Company K, “JP-K-001”, for patient XX should be represented in A.1.12, Identification
Number of the Report which is Linked to this Report.
In a contrasting example, Hospital X also reports AE2 to Company F. Company F had not
previously received an AE concerning Patient XX, and therefore there is no linked report and
A.1.12 is not populated. As in the first example concerning ICSR1, ICSR8 is a simple single
report from a company to a regulator.

Example of Linking Three Separate Adverse Events Affecting the Same Patient
Patient XX later suffers a third, separate and distinct adverse event, AE3. Hospital Y reports
AE3 to Company K who then in turn sends ICSR9 to Regulator. Population of relevant fields
for this new case is illustrated in the ninth row of the table. Company K populates A.1.0.1
with Company K’s (case) safety report unique identifier “JP-K-003”. Company K assigns a
new (case) safety report unique identifier “JP-K-003” because “JP-K-001” and “JP-K-002”, as
described above, represent separate, adverse events. Company K populates A.1.10.2 with “JP-
K-003” because company K is the initial sender of the report. The previous reports from
Company K, “JP-K-001” and “JP-K-002”, for patient XX should be represented in the
repeatable field A.1.12, Identification Number of the Report which is Linked to this Report.

Patient HP Company
XX ICSR1
K
ICSR2 ICSR3 ICSR4
AE1 X B C D R

FU E ICSR5(initial)
T
ICSR6(follow-up)
i
m
ICSR7
e AE2 X K
ICSR8
F

ICSR9
AE3 Y K

AE: Adverse Event report(case)

HP: Hospital observing the event
Report of AE
ICSR report
FU : Follow up

24
 Data Elements for Transmission of Individual Case Safety Reports

Tabular representation of fields contents for the above examples

A.1.0.1. A.1.10.2 A.1.11.1 A.1.11.2 A.1.12

ICSR1(K) JP-K-001 JP-K-001

ICSR2(B) JP-B-001 JP-B-001

ICSR3(C) JP-C-001 JP-B-001 B JP-B-001

ICSR4(D) JP-D-001 JP-B-001 B JP-B-001

C JP-C-001

ICSR5(E) JP-E-001 JP-E-001 *

ICSR6(E) JP-E-001 JP-E-001 *

ICSR7(K) JP-K-002 JP-K-002 JP-K-001

ICSR8(F) JP-F-001 JP-F-001

ICSR9(K) JP-K-003 JP-K-003 JP-K-001

JP-K-002

*These cases have different dates of most recent information (A.1.7)

25