Morbidity and Mortality Case Submission Form Survey

Morbidity and Mortality Case Submission Form

Thank you for participating in the M&M Case Submission process. Please use the form below to tell us about the case you feel will be of interest. You may submit a case which you did not personally participate.

1. What was the location of the case?

What was the location of the case? Dallas VA Hospital

TRSH

Dallas Children's Hospital

PHHS Outpatient Center

Zale Lipshy University Hospital

Parkland 2nd Floor

Parkland 3rd Floor

Chronic Pain (Univ., PMH, VA)

Acute Pain - all locations

St. Paul University Hospital

Univ. Outpatient Center (OSC - West Campus)

2. What was the approximate date of the case.

	MM		DD		YYYY		HH		MM	AM/PM
Date	What was the approximate date of the case. Date Month	/	Day	/	Year		Hour	:	Minute	AM or PM

3. Please identify the anesthesia team members (if known).

Please identify the anesthesia team members (if known). Faculty
Resident
Medical Student
CRNA
Student CRNA

4. Case description:

Case description:

5. Please list the specific learning or teaching point(s) of this case.

Please list the specific learning or teaching point(s) of this case.

6. Please list the specific learning or teaching point(s) of this case.