Please read instructions carefully before completing. Adverse events are defined as any negative unexpected or undesirable event(s) that occur following a surgical procedure that is not due to the underlying disease process or injury.
Instructions:
1.) Adverse events are graded as follows:
IEvent requires minimal (e.g. simple UTI)or no treatment and has NO effect on outcome.
II Event requires medical or surgical treatment and has no permanent or prolonged negative effect on outcome.
III Event requires medical or surgical treatment and will have a permanent or prolonged negative effect on outcome.
IV Event Results in death.
2.) The effect of AE on LOS is graded as follows:
I Event increases LOS by 1-2 days
II Event increases LOS by 3-7 days.
III Event increases LOS by 7-14 days
IV Event increases LOS by > 14 days
Is this admission due to an adverse event(s) from previous spinal surgery? / No Yes :If yes, from which institution – TWH Other
NO ADVERSE EVENTS
/INTRAOPERATIVE AE – YES NO
A.) MEDICAL ADVERSE EVENT(S) : Is Patient DNR? Yes No Unknown Medical Adverse Events / 1.) AE Grading / 2.) LOS Grading
I / II / III / IV / I / II / III / IV
Arrhythmia / / / / / / / /
Asthma / COPD exacerbation / / / / / / / /
Angina – new onset / unstable / / / / / / / /
Bowel Ileus / / / / / / / /
Bowel obstruction / / / / / / / /
Cerebrovascular – CVA / TIA / / / / / / / /
Coagulopathy / / / / / / / /
CHF / / / / / / / /
DVT / / / / / / / /
Delirium / / / / / / / /
GI bleed / / / / / / / /
MI / Cardiac Arrest / / / / / / / /
Pressure point -skin / / / / / / / /
Pressure point –peripheral nerve / / / / / / / /
Pneumonia / / / / / / / /
Pulmonary Embolus / / / / / / / /
Sepsis / / / / / / / /
UTI- Lower tract Upper tract / / / / / / / /
Over-Narcotized / / / / / / / /
OTHER ______/ / / / / / / /
B.) SURGICAL ADVERSE EVENTS TO BE FILLED OUT BY SURGEONS – STAFF / FELLOW / RESIDENT
Surgical Adverse Events
/ 1.) AE Grading / 2.) LOS GradingI / II / III / IV / I / II / III / IV
General
Bone graft harvesting site / / / / / / / / CSF leak - post-op / / / / / / / /
Graft - dislodgement / failure / / / / / / / /
Hardware – loosening / failure / / / / / / / /
Hardware misplacement / / / / / / / /
Hematoma – no neurologic sequelae / / / / / / / /
Hematoma – with neurologic sequelae / / / / / / / /
Inadequate decompression / / / / / / / /
Incorrect-diagnosis / / / / / / / /
Neurological Deficit - New / Increased vs. preoperative
Cord - Complete / / / / / / / / -Incomplete / / / / / / / /
Root – Motor / / / / / / / /
- Sensory (incl. Neuropathic pain) / / / / / / / /
Bladder (including retention) / / / / / / / /
Bowel
/ / / / / / / / Sutured drain / / / / / / / /
Wound dehiscence / / / / / / / /
Wound infection – superficial / / / / / / / /
Wound infection - deep / / / / / / / /
Wrong side / site surgery / / / / / / / /
Cervical
Airway / / / / / / / / Dysphagia / / / / / / / /
Horner’s Syndrome / / / / / / / /
Laryngeal nerve – superior / inferior / / / / / / / /
Skull penetration (i.e. – pins) / / / / / / / /
Tracheal/Esophageal injury / / / / / / / /
Vascular injury – Arterial Venous / / / / / / / /
Thoracic
Horner’s Syndrome / / / / / / / / Pneumo / Hemothorax – intra / post -op / / / / / / / /
Vascular injury – Arterial Venous / / / / / / / /
Lumbar
Vascular injury – Arterial Venous / / / / / / / /
Visceral injury / / / / / / / /
Urethral injury / / / / / / / /
Other
/ / / / / / / / Other
/ / / / / / / / Other
/ / / / / / / / Comments:
Version 5 last updated: January 2006