1. Morbidity and Mortality
Dr. Claritza Rios
Dr. Brijal Patel
Dr. Trushar Naik
Kings County Hospital Center
SUNY Downstate
Department of Emergency Medicine

2. History

3. Physical

4. Labs / Radiololgy / EKG

5. Assessment and Plan

6. ED Course
If relevant to case, include time stamps & dates (most cases have time as an important factor)
May need few slides

7. Was standard of care met?

8. What went wrong? / Points of Error

9. Types of Errors Description of types of error
Does it help to classify errors in the case?

12. Clinical pearls (1-2 slides)
If something clinical was involved – such as missed diagnosis, non-recognition of sick patient – include relevant pearls
Red flags for why this patient has potential for bad outcome
Possible important clinical clues to the final diagnosis
Pitfalls encountered in this diagnosis
Avoid the broad overview of clinical diagnosis unless it’s something rare and few people are aware of it

13. Systems Issues (2-4 slides) This should be an important part of presentation
What else went wrong that led to bad outcome?
Busy ER
No repeat assessment
Delays in care
Radiology
Med admin
Consults
Etc

14. Process Improvement What can we do to fix problem?
Is a change in policy needed?
Education of Drs re: clinical diagnosis
Improvements to nursing/ancillaries
Communications w/other depts – radiol, consults, admitting services
Etc
How can we change our thinking/actions to avoid the pitfalls