Surgery M&M Form

Resident Name

Attending Name

Hospital

RRMC
SMH
OV
VA

Service (select from dropdown)

Other Service Involved?

Patient Information

MRN

Name

Admission Date

Date of Surgery

DC/Death Date

Admitting Diagnosis

Procedure Performed/Care Provided

Complication

Background (Patient history, indication for procedure/care, relevant labs & imaging, procedure details related to complication, hospital course, recognition of complication and management)

Assessment

What Happened?

Why did it occur?

Individual Factors

Team Factors

Patient Factors

Environment

Rules/Policy

Organization

Structural Vulnerabilities

Other

Was this complication preventable?

Yes
No

Clavien-Dindo Classification

1 - Any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, or radiological interventions (acceptable therapeutic regimens are antiemetics, antipyretics, analgesics, diuretics, and electrolytes). Wound infections opened at the bedside are included in this category.
2 - Requiring pharmacological treatment with drugs other than such allowed for grade 1 complications: blood transfusions, antibiotics, TPN, etc.
3a - Surgical, endoscopic, or radiological intervention under regional/local anesthesia
3b - Surgical, endoscopic, or radiological intervention under general anesthesia
4a - Life-threatening complication requiring ICU management with single organ dysfunction or permanent loss of organ function (e.g., dialysis)
4b - Life-threatening complication requiring ICU management with multi-organ dysfunction
5 - Death

Health Equity Score

Grade 0 - No issues
Grade 1 - Minimal impact on outcome
Grade 2 - Significant impact on outcome
Grade 3 - Led to a life-threatening outcome

Literature Review

1.

2.

3.

4.

5.

Recommendations (Proposed action to prevent future events)

Identify the learning points from the case

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