UNC Department of Surgery/Confidential Peer Review
UNC Liability Insurance Trust Fund
Confidential Patient Information for Internal Use to Support Quality Improvement
DATE OF COMPLICATION __________________________
NAME: ________________________________________
Do Not Copy
Revised 7/2005
SERVICE ______________________________________________
UNIT # _____________
OPERATION (S) __________________________________________________________
NO _______
COMPLICATIONS ______________________________________________________________________________________________________
TYPE OF MORBIDITY / MORTALITY:
____ A
____ B
____ C
____ D
____ E
____ F
____ G
____ H
____ I
____ J
____ K
____ L
____ M
Wound separation / dehiscence
Wound infection/necrosis
Post-op abscess
Anesthetic complication
Operative injury to normal organ
Intraop or postop bleeding
Line complication
Medication error
Transfusion error
Thromboembolic
Atelectasis/pneumonia
ARDS
Cardiac arrhythmia
____ N
____ O
____ P
____ Q
____ R
____ S
____ T
____ U
____ V
____ W
____ X
____ Y
Myocardial infarction
Small bowel obstruction
Anastomotic leak, stricture, etc.
GI Bleed
Stroke / Seizure
Peripheral nerve injury
Urinary tract infection
Renal failure
Shock/sepsis
Multiple organ failure
Death
Other
TO BE COMPLETED AT M&M CONFERENCES
FACTORS IN MORBIDITY/MORTALITY
I.
page MUST be completed.*
____Unavoidable morbidity or mortality, due to:
1.
2.
3.
II.
Course of disease; occurred despite appropriate treatment, intervention.
Patient/family refused or non-compliant with recommended treatment.
Other:________________________________________________
____Potentially avoidable morbidity or mortality, due to:
1.
2.
3.
4.
5.
6.
III.
*Summaries on reverse side of this
Misdiagnosis:
Attending:____________________________________________
Delay in diagnosis:
Attending: ____________________________________________
Technical performance:
Attending: ____________________________________________
Delay in treatment: occurred because appropriate preventative measures not taken.
Attending: ____________________________________
Equipment problem – user error.
Attending:_____________________________________
Other: ________________________________________
UNC Department of Surgery/Confidential Peer Review
UNC Liability Insurance Trust Fund
Confidential Patient Information for Internal Use to Support Quality Improvement