These conferences involve an analysis of cases that provide significant opportunities for improvement. The Pulmonary Consult and ICU Fellows will preside over the M&M. All attendings and on-site fellows are expected to attend.

The following framework should be used:

• Background:
  • Provide brief History of Present Illness (HPI).
  • List Past Medical History (PMH), Past Surgical History (PSH), Family History (FH), Social History (SH), Medications (Meds), and known Allergies.
  • Describe the clinical examination.
• Timeline of Events
  • State the date/time.
  • Discuss the patient’s clinical status or any changes in status.
• Adverse events/outcomes triggering case presentation:

Case	Yes	No
Unexpected death
Medical or surgical complication
Delay in care
Delay in Diagnosis
Prolonged medical care in setting of poor prognosis
Other

• Review of Pertinent Literature:
  • Provide the title.
  • Indicate the level of evidence.
  • State the type of study.
• Factors contributing to adverse outcomes:

Factor	Yes	No
Communication: e.g., inadequate handoffs; incomplete clinical information
Coordination of care: e.g., involving multiple services and/or care sites
Volume of activity/workload: e.g., increased clinical volume and /or perception of workload
Escalation of care: e.g., delay or failure to involve more senior physicians or nurse
Recognition of change in clinical status: e.g., delay or failure to recognize changing clinical signs +/or symptoms
Other Factors:

• Root Cause Analysis Fishbone Diagram:

• Comments and discussion: