2. SUMMARY OF OR EVENTS REPORTED Data Range: TOTAL CASESST - ORNT - OR TOTAL COMPLICATIONS Dental Damage / Lip Lac. N / V Recall Regional Complication Ischemia / AMI Cardiac Arrest / Green Button Hypotension Hypoxia Re – intubation within 48 hrs Other (Define) Deaths PRIVILEGED DOCUMENT: Pursuant F.S. 395.0191, 395.0193, 395.0197, 766.101, and/or F.S. 766.1016 this document is privileged and confidential. It is not subject to discovery. DO NOT copy, print, forward, or release.

3. Morbidity Report Morbidity Report DatePt. NameMR #ComplicationAttendingResident PRIVILEGED DOCUMENT: Pursuant F.S. 395.0191, 395.0193, 395.0197, 766.101, and/or F.S. 766.1016 this document is privileged and confidential. It is not subject to discovery. DO NOT copy, print, forward, or release.

4. DatePatient NameMR #Cause of DeathAttendingResident Mortality Report

5. Case for Discussion

10. Characterize the incident  No adverse outcome  Near miss (no adverse outcome)  Major adverse outcome  Catastrophic adverse outcome (grim prognosis)  Sentinel event (death)

11. Classification/Competencies The issue occurred as a problem related to (check all that apply):  Medical knowledge  Patient care provided/not provided  Communication/Interpersonal skills  Professionalism  Practice-based learning and improvement  Systems-based practice

12. What I would do differently in same/similar case

13. 1.Insert point #1 here and describe……. 2.Insert point #2 here and describe……. Division of Pediatric Anesthesiology

14. References: