Surgical ServiceName of PresenterDate
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SituationStatement of the Problem
Admitting Diagnosis:Procedure Performed/Care provided:Complication:
2
BackgroundClinical Information Pertinent to Adverse Outcome
Pertinent patient historyIndication for surgical procedure/carePertinent labs and imagingProcedural details related to complicationHospital course related to complication or recognition of the complicationManagement of complication
3
BackgroundClinical Information Pertinent to Adverse Outcome
Pertinent patient historyIndication for surgical procedure/carePertinent labs and imagingProcedural details related to complicationHospital course related to complication or recognition of the complicationManagement of complication
4
AssessmentError Analysis
5
6
Complication
Individual factors
Cause
Effect
AnalysisRoot Cause Analysis
Team factors
Patient factors
Environment
Rules/Policy
Organization
Enter contributingfactors here
Enter contributingfactors here
Enter contributingfactors here
Enter contributingfactors here
Enter contributingfactors here
Enter contributingfactors here
Review of LiteratureEvidence-based practice
7
Review of LiteratureEvidence-based practice
8
RecommendationsProposed Actions to Prevent Future Similar problems
9
Guidance notes to presenters
Situationis the statement of the problem. It allows the audience to focus their attention to the pertinent points in the case related to the complications.
10
Background:here you provide clinical information pertinent to adverse outcome:Patient History : Pertinent HPI / PMH / PSH / meds)Indication for Intervention: Important to know thought process into performing an operationLabs and Imaging Studies: Only show pertinent labs and imagesProcedural Details: Describe technical or physiologic details related to outcomeHospital Course: Present non-procedural events related to outcome (Be brief, i.e., no need to list when patient passed flatus)Recognition of the Complication: State how/when complication was recognizedManagement of Complication: Describe the steps taken to manage the complicationMAKE THIS PART SHORT & SWEET!
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Assessment & Analysis:trainee presenters often neglect or are weak aterror analysis. Be prepared to identify and discuss the possible cause(s) of the complication:What happened? (Error analysis): Describe sequence of events leading to adverse outcomeWhy did it occur? (Root Cause analysis):Try to identify the root case of the complication i.e. what “allowed’ this complication to occur, what aspects of system failed and why? If you could go back what would you change to prevent this complication from occurring?
12
Review of literature:here you present appropriate literature pertinent to the complication. What is the best evidence related to this avoiding this complication?This may relate to:Identification of complicationManagement of complicationPrevention of complication
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Recommendations:This is another area where trainee presentations could be improved.Trainees are often good at discussing the complication but do not list recommendations for the audience that can help prevent these complications.You should:Identify how the problem could have been prevented or better managedIdentify the learning points from the case
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