[hospitalname]- d p h h s（(hospitalname)- d s p h h）（5页）.docVIP

Trauma Committee Attendance Date Time: Place: Chair: Attendees Program/Service/Unit/Department Visiting non-committee members Program/Agency Trauma Committee Minutes/Documentation Meeting date: Topic Opportunities for Improvement Discussion / Conclusions Action Plan Correction/Solution Follow-Up Implementation Evaluation Method for Monitoring Outcome/Loop Closure Responsible Case reviews Chart # 9999 ED 12/15/03 Issue: Undertriage providers 7 2 Injured adult with SBP 80 had no Full Trauma TA. TMD review concluded pt. needed Full TTA was undertriaged. Committee agreed 1/20/04 Letters from TMD/TC to be sent to ED RN 7 and physician 2, ED medical director ED nursing director with rationale, TTA criteria, and expectation of compliance and documentation. Review TTA criteria @ ED Committee ED staff meeting Letters sent 1/24/04 TTA criteria reviewed @ ED committee 1/28/04 ED Staff Meeting 2/01/04 Audited next 15 trauma pts with hypotension for this RN and next 12 trauma pts with hypotension for this physician over 6 months (54 pts meeting TTA criteria for all staff audited). No recurrence of undertriage. Loop closed. Will re-monitor for recurrence of issue 10/05 Letter to MD; TMD Letter to RN, audit; TNC. Tracking; TNC Topic Opportunities for Improvement Discussion / Conclusions Action Plan Correction/Solution Follow-Up Implementation Evaluation Method for Monitoring Outcome/Loop Closure Responsible Chart # 8888 Issue: Burn transfer, airway compromise, provider 47. Explosion caused 18% burn on adult, including some 3rd degree on hands, wheezing respirations. Transferred to burn center without ETT. 2nd level review concluded patient should have been intubated prior to transfer. Letter received from burn center requesting same. Committee agreed with conclusion. Letter (due 9/15)