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