Resident Practice Based Improvement Log

Department of Surgery

Stanford University School of Medicine

Instructions:

-Residents should complete the PBI form for each QI M&M they present

-Please submit to JoAnn Smithson at

-These entries can also be logged on MedHub in order for the GME to track our QI/PBI initiatives and will be discussed during your biannual meetings with your Program Director.

Case Information:

Your Name:
Date of QI M&M:
Date of Surgery:
Diagnosis:
Operation:
Complication:
Readmission (Y/N):

Case Summary:

Clavien-Dindo Classification (Select one):

 / Grade I / Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions
 / Grade II / Requiring pharmacological treatment with drugs other than such allowed for grade I complications (Blood transfusions and total parenteral nutrition are also included)
 / Grade IIIa / Requiring surgical, endoscopic, or radiological intervention – not under general anesthesia
 / Grade IIIb / Requiring surgical, endoscopic, or radiological intervention –under general anesthesia
 / Grade IVa / Life-threatening complication (including CNS complications) requiring ICU management – single organ dysfunction (including dialysis)
 / Grade IVb / Life-threatening complication (including CNS complications) requiring ICU management – multiorgan dysfunction
 / Grade V / Death of a patient

Preventable:

 / Preventable /  / Maybe Preventable /  / Not Preventable

Complication Analysis (check all appropriate fields):

Patient Factors
 / Comorbidities
Team Factors
 / Fatigue /  / Procedure Violation /  / Time Pressures
 / Performance Lapse /  / Poor Situational Awareness /  / Failure to Check Equip.
 / Lack of Knowledge /  / Lack of Skill /  / Lack of Judgement
Equipment
 / No Briefing /  / Poor Coordination of Care /  / Poor Communication
 / Understaffing /  / Inappropriate Help/Support /  / Unworkable Policy
Environment
 / Equipment Failure /  / Unfamiliar Equipment /  / Lack of Equipment

What can the hospital do differently as a result of this experience?

What would you do differently as a result of this experience?

What self-improvement and learning goals have you set?

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