SASM Proforma, Documentation and Programs
Proformas
Forms
for completion by medical personnel
Guidelines
for Assessors
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Proformas for each relevant death are sent to the Consultants involved. The surgical and anaesthetic pro forma are sent to the Consultant Surgeon who is asked to complete the surgical pro forma and return this to the relevant office. He / she then forwards the anaesthetic pro forma to the appropriate Consultant Anaesthetist who completes his / her form and returns it to the office. For operative deaths the entire surgical pro forma is completed by the surgeon. In non-operative cases a limited data set is collected and for terminal care admissions only the nature of the malignancy is required.
The proformas are anonymised on receipt in the appropriate office. They are then assessed by a consultant surgeon and anaesthetist and an assessment form completed. If either assessor believes that lessons may be learned from the case, or if the treatment was considered to be sub-optimal, the case notes are requested. These are then passed to another consultant who is asked to complete a detailed case note assessment. This process is undertaken in approximately 15% of cases. The resulting assessment is then returned to the Consultants involved in the case. This part of the process is not anonymous but remains highly confidential.
Finally all identifying data such as names of patients, hospitals, dates, etc are removed from the reports which are then collated in booklets and distributed to all consultants and trainees at intervals. The diagnosis on admission, confirmed diagnosis, types of operations and cause of death are READ 2 coded and all the factual data are then entered into the database.
Adverse Events in Management Codes
We have developed a coding system for "Adverse Events in Management" based on the READ2 structure as we were unaware of any similar coding system. Anyone interested in this would be welcome to a copy of our codes which are under constant review and improvement.