Trauma Center Performance Improvement And Patient Safety Plan (Page 8 of 9) in pdf

PERFORMANCE IMPROVEMENT REVIEW FORM

APPENDIX C

Patient Name:

Age:

Trauma Reg #:

Med Rec#

Admit Date:

Secondary Review Date:

M.D./Service:

Trauma Band #

PI Case Summary:

Clinical Indicators:

Determination:

Preventability:

CF/J:

 Trauma Death ( Date: ______________ Time: ___________)

 Trauma patients with ISS > 9 and ED length of stay > 2 hours for patients transferred out

 No Trauma Team activation for all patients with initial BP< 90

 Trauma Team activation criteria not followed

 EMS scene time > 20 min for all patients with an ISS > 15 or all penetrating trauma from scene

 EMS transport time > 45 minutes

 Patients with GCS < 8 without definitive airway established by EMS

 Patients with GCS < 8 without definitive airway within 5 minutes of ED arrival

Chest tube not placed for pneumothorax or hemothorax within 15 minutes of diagnosis

 Inability to obtain vascular access in a patient with unstable vital signs

 Denial of transfer by higher level of care facility

 Required/appropriately sized equipment not immediately available when requested

 EMS run report not left at hospital by EMS

 Infusion > than 40ml/kg crystalloid within 2 hours in a ped patient with normal vital signs

 Injuries diagnosed 24 hours after admission

 Trauma patients who return to the ED and require admission within 72 hrs.

 Complication_______________

 Other_______________

Contributing Factors/Judgment:

Opportunity for Improvement

Determination:

Death Preventability:

 Yes

1. Delay in Diagnosis

6. Error in Technique

SR = System Related

UM = Unanticipated Mortality with OFI

 No

2. Error in Diagnosis

7. Equipment ssue

DR = Disease Related

AM = Anticipated Mortality with OFI

3. Error in Management

8. Triage Issue

PR = Provider Related

M = Mortality without OFI

4. Communication Issue

9. Other_______

CD = Cannot be determined

5. Timeliness/Availability

Trauma Director/Other Physician Review:

Signature:

Date:

Performance Improvement Actions (s):

Date Completed

 None Required

Trend Evaluation:

 Trend

 Re-evaluate in 3 months

 Guideline or Protocol

 Letter with Follow-up Required

 Re-evaluate in 6 months

 Education-Specify:

 Monitor until resolved

 Enhanced Resources, Facilities, Communication

 FYI Letter

 Counseling

 M&M Peer Review/Operational Committee Presentaion

 Privilege or Credentialing Action

 Referral to _____________

 TRAC PI Committee

RE-EVALUATION DATE(S):

Corrective Action Follow-up Notes:

Created 01-12-2012

Page 8

LOOP CLOSURE DATE:

Trauma Center Performance Improvement And Patient Safety Plan Page 8

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