Practice Based Improvement Log - Stanford Medicine
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 smithson@stanford.edu
- 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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