UCLA Division of General Surgery
Morbidity and Mortality Report Form
Date Submitted:
Resident MD:
Attending MD:
Hospital:
RRMC
Surgical Service:
Situation:
Admitting Diagnosis:
SMH
VA
Date of Admission:
Date of DC/ Death:
MRN #
OVMC
Out- Pt
Procedure Performed/Care provided:
Complication:
Background: (Pertinent patient history, indication for surgical procedure/car, pertinent labs and imaging, procedural details related
to complication, hospital course related to complication or recognition of the complication, management of the complication)
Other Service Involved?
Assessment:
What happened?
Why did it occur?
Root cause analysis
Individual Factors
Environment
Team Factors
Rules/Policy
Patient Factors
Organization
The above and any attachments are confidential and protected from disclosure pursuant to California Evidence Code
Section 1157 which protects the proceedings and records of organized committees of medical staffs having the
responsibility of evaluation and improvement of the quality of care rendered in the hospital.
UCLA Division of General Surgery
Morbidity and Mortality Report Form
Review of Literature
Recommendations: Proposed Action to Prevent Future Similar Problems
How could this problem have been prevented or better managed?
Identify the learning points from the case
NOTE
Please submit this form to Dr. Tillou and Hallie Chung.
The above and any attachments are confidential and protected from disclosure pursuant to California Evidence Code
Section 1157 which protects the proceedings and records of organized committees of medical staffs having the
responsibility of evaluation and improvement of the quality of care rendered in the hospital.