Clinical case report

Gender *

Female

Male

DOB

MM

DD

YYYY

Date of admission *

MM

DD

YYYY

Grade of complication *

As per RACS standards

Grade 1 - Any deviation from the normal post-operative course not requiring surgical, endoscopic or radiological intervention. This includes the need for certain drugs (e.g. antiemetics, antipyretics, analgesics, diuretics and electrolytes), treatment with physiotherapy and wound infections that are opened at the bedside.

Grade 2 - Complications requiring drug treatments other than those allowed for Grade I complications; this includes blood transfusion and total parenteral nutrition (TPN).

Grade 3a - Complications requiring surgical, endoscopic or radiological intervention. - intervention not under general anaesthetic

Grade 3b - Complications requiring surgical, endoscopic or radiological intervention. - intervention under general anaesthetic

Grade 4a - Life-threatening complications; this includes CNS complications (e.g. brain haemorrhage, ischaemic stroke, subarachnoid haemorrhage) which require intensive care, but excludes transient ischaemic attacks (TIAs). - single-organ dysfunction (including dialysis)

Grade 4b - Life-threatening complications; this includes CNS complications (e.g. brain haemorrhage, ischaemic stroke, subarachnoid haemorrhage) which require intensive care, but excludes transient ischaemic attacks (TIAs). - multi-organ dysfunction

Grade 5 - Death of patient

Complication type *

Infection

Vascular or nerve injury

Instability or dislocation

Fracture

Anaesthetic related

Post-op medical issue

DVT/PE

Theatre related (eg sterilisation, robot, equipment, staffing)

Ward related (eg fall)

Other (please outline below)

Did the complication lead to a readmission? *

Yes

No

Did the patient have an unplanned return to theatre? *

Yes

No

Was there an unplanned admission to ICU or HDU? *

Yes

No

Did the complication lead to death? *

Yes

No

Was there an issue with access to theatre or timing of surgery? *

Yes (describe below)

No

VTE prophylaxis used *

Heparin or LMWH (eg clexane)

Warfarin

Aspirin

NOAC (eg rivaroxaban)

TEDS/SCDS

None

In hindsight, could the patient's management been improved in any of the following areas?

Pre-operative management

Decision to operate at all

Choice of operation

Timing of operation

Intra-operative management or technical skill

Post-operative care

Equipment or implant choice

Other (please outline below)

Would you like to discuss the case at our next M&M meeting? *

Yes

No