1 Start 2 Complete Form Instructions Complete the form. Required questions are marked with a * red asterisk. Make sure to click "Submit" when you are finished to send the form to Geisinger Continuing Education. Date of Activity When was the activity held? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202520262027 File / Activity Number * This is the unique identifying number for your program, beginning with R. (Example: R1234-27) Name of Program What is the title of your program? Email * What is your email if follow up is needed? Continuing Education Associate's Email * Please provide the email of the Continuing Education Associate from your department who assists with paperwork. They will receive a copy of this form for their records. Type of Program * M and M Tumor Board M and M Form Speaker/Facilitator Case 1 * Reported Event/Complication How would you classify this event? (Check one) * Incident Failure Serious Event Death Other... How would you classify this event? (Check one) Other... Patient Harm/Outcome (Check one) * No Harm Minimal Harm Major Harm Death Not Determined Primary Contributing Root Cause - Was a Result of: (Check all that apply) * Communication Supervision Indication Technique Treatment Concept Judgment Error Aftercare System Issue Patient Engagement Patient Selection Co-Morbidities Injury Severity Primary Contributing Root Cause - Was Equivocal: (Check one) * No root cause evident Other... Primary Contributing Root Cause - Was Equivocal: (Check one) Other... What Must be Done Differently? (Check all that apply) * Education Guideline/Protocol PI Committee/Peer Review MIDAS Report Was Filed Other... What Must be Done Differently? (Check all that apply) Other... Case Discussion - Did the discussion focus on blaming others? (Check one) * Not at all, it was blame free Very Little Somewhat A Lot Very Much, clear blame was placed Case Discussion - Was the discussion interprofessional? (Check one) * Yes No Check professions present: (Check all that apply) * Physicians Pharmacists Advanced Practitioners Nurses Other... Check professions present: (Check all that apply) Other... Was there an additional case? Yes No Case 2Reported Event/Complication How would you classify this event? (Check one) * Incident Failure Serious Event Death Other... How would you classify this event? (Check one) Other... Patient Harm/Outcome (Check one) * No Harm Minimal Harm Major Harm Death Not Determined Primary Contributing Root Cause - Was a Result of: (Check all that apply) * Communication Supervision Indication Technique Treatment Concept Judgment Error Aftercare System Issue Patient Engagement Patient Selection Co-Morbidities Injury Severity Primary Contributing Root Cause - Was Equivocal: (Check one) * No root cause evident Other... Primary Contributing Root Cause - Was Equivocal: (Check one) Other... What Must be Done Differently? (Check all that apply) * Education Guideline/Protocol PI Committee/Peer Review MIDAS Report Was Filed Other... What Must be Done Differently? (Check all that apply) Other... Case Discussion - Did the discussion focus on blaming others? (Check one) * Not at all, it was blame free Very Little Somewhat A Lot Very Much, clear blame was placed Case Discussion - Was the discussion interprofessional? (Check one) * Yes No Check professions present: (Check all that apply) * Physicians Pharmacists Advanced Practitioners Nurses Other... Check professions present: (Check all that apply) Other... Tumor Board FormAssess the Impact of the Tumor Board Discussion on Treatment Plan. The moderator should complete the following table by selecting in the column that best describes the outcome of the discussion. 1. Case Number or ID * Please provide the Case Number or ID. Treatment Options * Accept treatment plan Modify treatment plan Group treatment plan consensus Other... Treatment Options Other... 2. Case Number or ID Please provide the Case Number or ID. Treatment Options Accept treatment plan Modify treatment plan Group treatment plan consensus Other... Treatment Options Other... 3. Case Number or ID Please provide the Case Number or ID. Treatment Options Accept treatment plan Modify treatment plan Group treatment plan consensus Other... Treatment Options Other... 4. Case Number or ID Please provide the Case Number or ID. Treatment Options Accept treatment plan Modify treatment plan Group treatment plan consensus Other... Treatment Options Other... 5. Case Number or ID Please provide the Case Number or ID. Treatment Options Accept treatment plan Modify treatment plan Group treatment plan consensus Other... Treatment Options Other... 6. Case Number or ID Please provide the Case Number or ID. Treatment Options Accept treatment plan Modify treatment plan Group treatment plan consensus Other... Treatment Options Other... Additional Comments: Leave this field blank
