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