PVESC Surgical Patient Complication Form

This purpose of this form is to document complications surrounding surgical cases managed by PVESC so that we can better identify areas of improvement through surveillance.

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Date of Submission *

Date of Incident *

Submitting Team Member *

First

Last

Patient Name *

Please Categorize the Complication (Check All That Apply): *

• Client Communication – Incorrect or inadequate owner financial prep
• Client Communication – Incomplete owner discussion around duration of hospitalization
• Client Communication – Incomplete owner prep for potential complications and/or prognosis
• Client Communication – Incomplete or Incorrect Discharge Instructions
• Pre-Op Complication – Inadequate patient care (resuscitation, antibiotics, pain management)
• Pre-Op Complication – Inaccurate or Delayed Diagnosis
• Pre-Op Complication – Delay to Surgery d/t Available Team or Equipment
• Anesthetic Complication – Peri-Operative Death
• Anesthetic Complication – Transfusion Products Unavailable
• Anesthetic Complication – Anesthetic Equipment Error
• Anesthetic Complication – Medication Error
• Surgical Complication – Intra-Operative Tissue Handling Error
• Surgical Complication – Equipment Failure
• Surgical Complication – Hemorrhage (unexpected, uncontrolled)
• Post-Operative Complication – Owner Non-Compliance with Post-Op Instructions
• Post-Operative Complication – Post-operative Infection
• Post-Operative Complication – Hemorrhage
• Post-Operative Complication – Incisional Dehiscence (Skin)
• Post-Operative Complication – Incisional Dehiscence (Internal)
• Post-Operative Complication – Other

If applicable, please indicate any of the steps below that have been taken to address complication:

ALL CHECK THAT

ALL Complications (ACTIONS TAKEN – CHECK ALL THAT APPLY):

• ER Surgery Team Lead notified
• Hospital Steward notified
• ER Manager notified

Client Communication (ACTIONS TAKEN – CHECK ALL THAT APPLY):

• Discussion with clients regarding general surgical expectations
• Discussion with PCC and ER Surgery Team Lead to verify accurate surgical estimates

Pre-Op and Anesthetic Complications (ACTIONS TAKEN- CHECK ALL THAT APPLY):

• Direct discussion with ER Surgery Team Lead and DVM guiding pre-op resuscitation
• Direct discussion with ER Surgery Team Lead and T/L regarding unanticipated anesthetic complications
• Direct discussion with inventory and ER manager regarding medication or equipment failure

Post-Op Complications (ACTIONS TAKEN – CHECK ALL THAT APPLY)

• Re-Explore pursued
• Extended hospitalization provided
• Financial reimbursement provided to client
• Culture obtained of any infected tissue; logged in post-op infection log
• Discussion with scribes to help clarify discharge instructions

Please include any additional details including other errors or other actions taken below:

Submit