Excessive Outside Distractions Primary Physician Cannot Be Reached Prolonged Interruption of Compressions Talking About the Patient Like They Aren't There Failure to Follow ACLS Protocol Unstructured Sign-Out Failure to Offer Standard of Care Something Really Good: __________ __________ __________ Breaking Sterile Field (Gloves/ Hands) Performing Procedure Outside Scope of Practice Incorrect Equipment Wrong Dose of Medication Failure to Fixate Equipment Suture Cut Incorrectly Ineffective CPR Inadequate PPE Unlisted Error: __________ __________ __________ Poor Operating Room Set-Up Poor History Taking Inappropriate Surgical Setting Failure to Provide Ventilation Scrub in Incorrectly Unnecessarily Delaying Procedure Making Excuses for Medical Errors Lack of Physician Follow- Through Failure to Provide Oxygen Closed Loop Communication Absent Needlessly Removing Caregiver/ Family Bad Ergonomics External Pressure/ Rushing a Procedure Critical Information Delayed Illegal Declaration of Death Unlisted Error: __________ __________ __________ Unsafe Foreign Objects in Operating Room Wrong Dose of Electricity Specialist Essential to Procedure Absent Wrong Defibrillator Setting Early Cessation of Resuscitation Efforts Breaking Sterile Field (Gown/Torso) Ineffective Defibrillation Procedure Performed Incorrectly Failure to Share Important Information Performing Procedure Beyond Level of Skill/Training Overconfident Physician Excessive Outside Distractions Primary Physician Cannot Be Reached Prolonged Interruption of Compressions Talking About the Patient Like They Aren't There Failure to Follow ACLS Protocol Unstructured Sign-Out Failure to Offer Standard of Care Something Really Good: __________ __________ __________ Breaking Sterile Field (Gloves/ Hands) Performing Procedure Outside Scope of Practice Incorrect Equipment Wrong Dose of Medication Failure to Fixate Equipment Suture Cut Incorrectly Ineffective CPR Inadequate PPE Unlisted Error: __________ __________ __________ Poor Operating Room Set-Up Poor History Taking Inappropriate Surgical Setting Failure to Provide Ventilation Scrub in Incorrectly Unnecessarily Delaying Procedure Making Excuses for Medical Errors Lack of Physician Follow- Through Failure to Provide Oxygen Closed Loop Communication Absent Needlessly Removing Caregiver/ Family Bad Ergonomics External Pressure/ Rushing a Procedure Critical Information Delayed Illegal Declaration of Death Unlisted Error: __________ __________ __________ Unsafe Foreign Objects in Operating Room Wrong Dose of Electricity Specialist Essential to Procedure Absent Wrong Defibrillator Setting Early Cessation of Resuscitation Efforts Breaking Sterile Field (Gown/Torso) Ineffective Defibrillation Procedure Performed Incorrectly Failure to Share Important Information Performing Procedure Beyond Level of Skill/Training Overconfident Physician
(Print)
Excessive Outside Distractions
Primary Physician Cannot Be Reached
Prolonged Interruption of Compressions
Talking About the Patient Like They Aren't There
Failure to Follow ACLS Protocol
Unstructured Sign-Out
Failure to Offer Standard of Care
Something Really Good: __________
__________
__________
Breaking Sterile Field (Gloves/ Hands)
Performing Procedure Outside Scope of Practice
Incorrect Equipment
Wrong Dose of Medication
Failure to Fixate Equipment
Suture Cut Incorrectly
Ineffective CPR
Inadequate PPE
Unlisted Error: __________
__________
__________
Poor Operating Room Set-Up
Poor History Taking
Inappropriate Surgical Setting
Failure to Provide Ventilation
Scrub in Incorrectly
Unnecessarily
Delaying Procedure
Making Excuses for Medical Errors
Lack of Physician Follow-Through
Failure to Provide Oxygen
Closed Loop Communication
Absent
Needlessly Removing Caregiver/
Family
Bad Ergonomics
External Pressure/ Rushing a Procedure
Critical Information Delayed
Illegal Declaration of Death
Unlisted Error: __________
__________
__________
Unsafe Foreign Objects in Operating Room
Wrong Dose of Electricity
Specialist Essential to Procedure Absent
Wrong Defibrillator Setting
Early Cessation of Resuscitation Efforts
Breaking Sterile Field (Gown/Torso)
Ineffective Defibrillation
Procedure Performed Incorrectly
Failure to Share Important Information
Performing Procedure Beyond Level of Skill/Training
Overconfident Physician
