Morbidity And Mortality Review Form

MORBIDITY AND MORTALITY REVIEW FORM
Date: [date]  Completed by: [text]
Date of Event: [date]
Case Identification: [text size=30 default="patient ID, med rec #, etc."]
Outcome:  [select name="outcome" value="Death|ICU Transfer|Readmission within 48 hours|Medication error|Other"] [conditional field="outcome" condition="(outcome).is('Other')"] [text default="outcome description" size=70][/conditional]
Brief summary of events leading to the adverse outcome:
[textarea]
Was the outcome preventable? [select name="preventable" value="No|Yes|Uncertain"] [conditional field="preventable" condition="(preventable).is('Yes')||(preventable).is('Uncertain')"] What might have been done to change the outcome? [text size=140 default="prevention details"][/conditional]
Is there clinical evidence to support individual practice change that may have altered the outcome? [select name="evidence" value="No|Yes"] [conditional field="evidence" condition="(evidence).is('Yes')"] [text size=140 default="evidence details"][/conditional]
Are there any system-based changes that may prevent similar future outcomes? [select name="system" value="No|Yes"] [conditional field="system" condition="(system).is('Yes')"] [text size=140 default="description of proposed system-based changes"][/conditional]
List three learning points from this case:
[text default="point #1" size=140]
[text default="point #2" size=140]
[text default="point #3" size=140]
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[checkbox memo="check box if you need more space for notes." name="notes" value=" "] [conditional field="notes" condition="(notes).is(' ')"] [textarea default="Additional space for notes"][/conditional]