Division of Cardiology Morbidity & Mortality Conference Summary
The Division of Cardiology's Morbidity & Mortality Conference discussed a case involving a patient with an LVAD presenting with "low flows," a delayed diagnosis of GIB, and delayed transfusion. The level ofCONTENT for the corresponding Medical Record Number (MRN) includes a timeline of events that led to adverse outcomes and medical errors. The conference aimed to identify areas for improvement in patient care to prevent such incidents from reoccurring.
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Presentation Transcript
Division of Cardiology Morbidity & Mortality Conference Date: **** Case Presented by *** Conference Facilitator: **** The records, reports, and other information described in subsection (3) and subsection (5.5) of this section shall not be subject to subpoena or discoverable or admissible as evidence in any civil or administrative proceeding. No person who participates in the reporting, collection, evaluation, or use of such quality management information with regard to a specific circumstance shall testify thereon in any civil or administrative proceeding. 2020 Colorado Revised Statutes, Title 25, section 25-3-109
M&M Mission What exactly did happen? How can we prevent this from happening again? How could this happen? To establish a safe venue to identify areas for improvement in patient care, while promoting professionalism, integrity and transparency.
Name of Conference Facilitator UPDATES
Updates Specifics about 1 project
The Good Stuff Some good things we did (collected by conference facilitator)
Presenter name CASE PRESENTATION
Case Summary Initials / Medical Record Number One-liner: Patient with LVAD p/w "low flows", dx of GIB delayed, transfusion delayed Level of Harm: Category F Temporary harm to patient & required intervention (see M&M Prep guide for levels)
Initials / MRN Case Details One-liner copied here.
Initials / MRN Case Details One-liner copied here.
0745 on Day 1 Medical error propagating 23:30 on Day 0 Describe presentation and context 0630 on Day 1 Context around medical error 0915 on Day 1 Outcomes of adverse event. 0815 on Day 1 Adverse event 0700 on Day 1 Context around medical error Delays in Care 00:30 on Day 1 Continue with context 0730 on Day 1 Medical Error propagating *** 0825 on Day 1 Adverse event continues 0800 on Day 1 Medical error propagating 0600 on Day 1 Medical error occurs 0900 on Day 1 Outcome of adverse event
Root-Cause Analysis Knowledge & Decisions Processes & Procedures Communication Adverse Event Organization Constraints Equipment Environment One-liner copied here.
Teaching That may fit before or after your fishbone diagram. Discuss content with quality and conference facilitation team. One-liner copied here.
Next Steps Issues Possible Solutions One-liner copied here.
