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