Do Not Copy

Revised 7/2005

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 # _____________

AGE _______

SEX _______

PARTICIPATING RESIDENT: ________________________ ATTENDING SURGEON ____________________________________________

SURGICAL DIAGNOSIS:________________________________________________________________________________________________
COMORBIDITIES: ______________________________________________________________________________________________________
OPERATION DATE _____________________
AUTOPSY: YES _______

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: ________________________________________

EFFECTS ON OUTCOME

_______ None
_______ Unknown
_______ Temporary sequelae
_______ Permanent sequelae
_______ Death

Related to a System Issue

____ YES (OR) _____ NO

____Analysis of cause of morbidity or mortality requires review by ________________ service.

ACTION RECOMMENDED _______ YES (OR) _______ NO

ACTION TAKEN:_________________________________________________________________

SIGNATURE_________________________________ _______________ DATE________________________

(TURN PAGE OVER)

Revised 7/2005

Do Not Copy
Revised 7/2005

UNC Department of Surgery/Confidential Peer Review

UNC Liability Insurance Trust Fund
Confidential Patient Information for Internal Use to Support Quality Improvement

Do Not Copy
Revised 7/2005

CASE SUMMARY:

DISCUSSION SUMMARY:

ACTION TAKEN / OTHER COMMENTS:

(MUST COMPLETE SIGNATURE/DATE)

Attending Moderator
Signature

DATE:

Revised 7/2005