Download Practice Based Improvement Log

Practice Based Improvement Log
Department of Surgery
Stanford University School of Medicine
Complete a practice based improvement log entry on every patient discussed during Morbidity
and Mortality Conference for whom you were the responsible resident (operating or admitting
surgeon). Submit the report to JoAnn Smithson. Discuss all of your practice based improvement
log entries with your advisor at your next formal advisor meeting.
Your Name:
M&M Number:
Date of Surgery:
Date of Report:
Patient Data
Description of complication/course of disease from M&M report here:
Outcome
Outcome (select the most appropriate field)
□
□
Outcome not affected by incident
Grade I: Minor, resolves or requires simple bedside procedure or antibiotics (examples:
wound infection, UTI)
□ Grade IIa: Life threatening, requires drug or TPN intervention that carries risk (examples:
pneumonia, arrhythmia, acute pancreatitis)
□ Grade IIb: Life threatening, requires invasive intervention (examples: CT guided abscess
drainage, re-operation)
□ Grade III: Associated with residual disability or organ loss (examples: stroke, iatrogenic
splenectomy)
□ Grade IV: Death
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Analysis
Which factors led to the incident? (check all appropriate fields)
Personal factors
□ fatigue
□ Illness of provider
□ lack of skill (technical skill)
□ lack of judgement
□ time pressures
□ performance lapse
□ Procedure violation
□ lack of knowledge
□ lack of experience
□ poor situational awareness
□ poor task prioritization
□ failure to check equipment
Team factors
□ no briefing
□ procedure violation
□ negative attitude of the surgical team
□ poor surgical team communication/coordination
□ poor communication/coordination between surgical and anesthesia teams
Equipment
□ equipment failure
□ unfamiliar equipment/monitoring
□ misleading arrangement of equipment
□ lack of equipment/monitoring
Environment
□ Unfamiliar surroundings
□ inappropriate help/support
□ patient condition
□ high pressure environment
□ bad working conditions
□ understaffing
□ unworkable policy/procedures
In your opinion this incident was:
□ preventable
□ not preventable
This incident belongs in the following error-category (more than one category can be
involved):
□ patient’s condition
□ personal factors (including human error)
□ team factors
□ environment/equipment factors (including technical failure)
□ organizational factors (hospital policy/procedures)
□ regulatory (governmental rules, insurance company rules)
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What do you suggest the hospital do to prevent and/or minimize damage in similar future
incidents?
What will you do differently in your own practice as a result of this experience?
As a result of this experience, what self-improvement and learning goals have you set for
yourself?
What learning activities will you use to achieve these goals.
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