1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Brief Overview of Case  Diagnosis  Complication

3. Introduction for Every Case  Complication  (e.g. anastomotic leak, return to OR)  Procedure  (e.g. Laparoscopic Low Anterior Resection)  Primary Diagnosis  (e.g. T3N0 Rectal Adenocarcinoma)

4. Clinical History  Provide a BRIEF Clinical History  HPI  PMH  Pertinent Findings/Films  Not all clinical information is necessary!

5. Analysis of Complication Was the complication potentially avoidable? – e.g. No: Patient received adequate prophylaxis but still had DVT or PE. Would avoiding the complication change the outcome for the patient? – e.g. No: Patient had DVT but died of systemic sepsis. What factors contributed the complication? – e.g. previous surgery, lack of communication between radiology and O.R., delay until chemotherapy, etc.

6. Supporting Data/Conclusions What have others written about this complication? – Describe textbook/literature methods of avoiding/managing complication. – Does the literature support the decisions made in this case leading to the complication? “Take home” points – i.e. what did you learn from this (what to do differently)? – Maximum of two specific points – Focused areas for intervention at any level of care – If one point is an individual lesson, the second should be a systems-level suggestion for change

7. Other points  Focus on causes and possible prevention  Consider more factors than the individual provider: e.g. patient, systems, equipment  It will be recommended that questions be held until the discussion period

8. Timeline of Key Events

9. Restate Complications  Identify all potential causes of the complications

10. Clinical Issues  How could/should the complications have been  Prevented  Ameliorated  Managed  What would you have done differently

11. The patient care issue occurred as a problem related to…..  Medical Knowledge  Patient care provided or not provided  Communication and interpersonal skills  Professionalism  Practice-based learning and improvement  Systems-based practice

12. Evidence Based Literature

13. The knowledge gaps are What we know…  There are known known's. These are things we know that we know. What is not known…  There are known unknowns. These are the things that we know we don't know.

14. Take Home Points