Morbidity and Mortality Dr. Claritza Rios Dr. Brijal Patel Dr. Trushar Naik Kings County Hospital Center SUNY Downstate Department of Emergency Medicine
History
Physical
Labs / Radiololgy / EKG
Assessment and Plan
ED Course If relevant to case, include time stamps & dates (most cases have time as an important factor) May need few slides
Was standard of care met?
What went wrong? / Points of Error
Types of Errors Description of types of error Does it help to classify errors in the case?
Clinical pearls (1-2 slides) If something clinical was involved – such as missed diagnosis, non-recognition of sick patient – include relevant pearls Red flags for why this patient has potential for bad outcome Possible important clinical clues to the final diagnosis Pitfalls encountered in this diagnosis Avoid the broad overview of clinical diagnosis unless it’s something rare and few people are aware of it
Systems Issues (2-4 slides) This should be an important part of presentation What else went wrong that led to bad outcome? Busy ER No repeat assessment Delays in care Radiology Med admin Consults Etc
Process Improvement What can we do to fix problem? Is a change in policy needed? Education of Drs re: clinical diagnosis Improvements to nursing/ancillaries Communications w/other depts – radiol, consults, admitting services Etc How can we change our thinking/actions to avoid the pitfalls