1. Shannon Kilkelly, D.O. Assistant Professor Department of Anesthesiology Vanderbilt University Medical Center

2.  Practitioner Problems vs System Problems  Focus Targets of Educational and Training Programs  $$$  Tort Protection  Governmental Regulatory Requirements  Improved Quality of Care for Our Patients

3.  Myoclonus during an Etomidate induction?  4 beat run of monomorphic VT?  Bradycardia during a retrobulbar block?  Dental Injury during Intubation?  Pneumothorax during Central Line Placement?  A non-judgemental, non-blame assigning way of describing events that potentially could have been, or actually were, harmful to our patients  Formerly called morbidities, mortalities, Adverse events, or Errors  Let Conscience and Common Sense Guide You

4.  Self Reporting via E- ACR systems  NACOR / AIRS  Intranet Online Reporting Systems  E-mail  Phone Calls  Curbsides  Post –op interviews  EHR Database Queries

10. MCE3: Patient stated that she was having difficulty understanding the anesthesiologist due to his accent. And because of the communication problem, she felt he was not listening to her concerns regarding her allergies. She stated that he kept questioning her regarding whether it was a true allergy or just a side effect. MCE3: Patient stated that she had a difficult time awakening and felt very groggy and felt that she was not able to get a breath. She stated that this was the worst time she has had in the last 5 surgeries.

14. CARE RELATED PROFESSIONALISM RELATED

15.  Class 1  Aspiration, cardiac arrest, Death < 48hrs post-op  Class 2  re-intubation (uneventful), Peri-op MI (non-fatal)  Class 3  HD stable Dysrhythmias, Bronchospasm  Class 4  Dental injury, blood wastage, urinary retention

16.  The Medical Record  H&P  Operative Reports  Pre-op RN paperwork  Circulating RN Documentation  Code Recording Sheets  Anesthetic Care Records  Billing Records / Pharmacy Charge Sheets  Banked data from OR / PACU / ICU monitors  Personal Interview*

17.  Start with the Material Witnesses  Face – to – face is best  If possible, make notes afterwards  Ask open-ended questions  Acknowledge expertise  Leave open the possibility of re-interview  Save the main event for last  Behavior and responses during the interview can be key in determining outcome

18. MORE LIKE THISLESS LIKE THIS

19.  The Bad Outcome was Anticipated  Care Appropriate  Care Potentially contributed to the outcome  Care definitely contributed to the outcome  The Bad Outcome was Unanticipated  Care Appropriate  Care potentially contributed to the outcome  Care definitely contributed to the outcome

20.  Practitioner Problem  History  Circumstance  Informal counseling  Peer Review Committee  Remediation  Reassignment  Limitation of clinical duty  Systems-Based Problem  Frequency of the event  Multiple practitioners  Multiple sites  QMM&I committee  Re-engineering of process  Workflow  Resource re-allocation

21. Quality and Patient Safety Director Morbidity, Mortality Improvement Committee Peer Review Committee Veritas VPIMS/Admin Data Phone Reports to Quality Office Direct Verbal/ Email Reports VC Clinical, Dept. Chair Division Chief Close Case Joint QMMI Conference Departmenta l MMI Conference Project Development- Assignment to individual/group Automated: Biochemical Markers Chart Scanning