UCLA DEPARTMENT OF SURGERY
SLTX MORBIDITY AND MORTALITY CONFERENCE
EVENT REPORT FORM
Date of Report:
Presenting Physician:
Patient Hospital ID#:
Primary Surgical Diagnosis:
Event: Post Tx:
ReDo # :
Complication (s) & Date (s):
Secondary Diagnoses:
CAD
Other:
HTN
Date of Admission:
Attending Physician:
Age:
Gender:
M
F
Primary Procedure:
Pre Tx (If death-may not need to be presented but needs write up) :
COPD
DM
PVD
Malnutrition
Cancer
Case Summary
Event(s) (check all that apply):
Intentional Re-operation within 2 days
Operation:
Unanticipated Re-operation w/in 30 days
Operation:
Readmission w/in 15 days of discharge
Post-discharge day #:
Unanticipated admission following clinic. Reason:
Related to “bedside” procedure. Reason:
Bleeding
Site:
# units transfused:
DVT
PE
HAT Portal Vein Thrombosis
Postop Prophylaxis
N
Y Type:
SCDs Heparin
Infection
Site:
Organism:
Treatment:
Fistula
Perforation/Rent
Abscess
Stricture
Site:
Treatment:
Anastomotic Leak
Site: Biliary:
GI:
Treatment:
T-Tube Complication
Was Protocol Followed:
Treatment:
Respiratory complication: Aspiration:
Reintubation:
Other:
Treatment:
Cardiac: AMI:
Arrhythmia:
Code:
Rapid Response:
Other:
Neurologic: CVA:
Seizures:
Treatment:
Death
Death within 30 days after DC
Withdrawal of Care:
Cause of death:
Autopsy performed Coroner’s Case #:
Results:
Communications or ethic issues
Other Complications (specify):
Other Service involved:
Lovenox
Event Code:
Administrative
System
Off-service
Technical; unpreventable
Medical; unpreventable
Technical; preventable
Outcome of Patient:
No sequela
No harm to patient but escalation of care
Irreversible organ damage
Death
Revised May 2010/lc
Medical; preventable
Resident action
Reversible damage to integrity of an organ
UCLA DEPARTMENT OF SURGERY
SLTX MORBIDITY AND MORTALITY CONFERENCE
EVENT REPORT FORM
Conclusion and PLAN OF ACTION (Indicate how it could be avoided in the future)
Literature Citation (minimum two)
(Completed by Performance Improvement Coordinator)
Presented
Not Presented
Does someone else need to be invited?
Did you contact the person?
Revised May 2010/lc