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1
Contents
1.
ABBREVIATIONS ............................................................................................................................. 4
2.
CLINICAL DIRECTOR’S REPORT ................................................................................................... 5
3.
EXECUTIVE SUMMARY ................................................................................................................... 7
4.
RECOMMENDATIONS FOR VASM CLINICAL STAKEHOLDERS.................................................. 9
5.
INTRODUCTION.............................................................................................................................. 11
6.
AUDIT PARTICIPATION AND AUDIT PROCESSES ..................................................................... 13
A
UDIT NUMBERS
.............................................................................................................. 13
6.1.
V
ERIFICATION OF AUDIT NUMBERS
.................................................................................... 14
6.2.
A
UDIT PARTICIPATION RATES
........................................................................................... 15
6.3.
H
OSPITAL
C
LINICAL
G
OVERNANCE
R
EPORTS
................................................................... 19
6.4.
D
EMOGRAPHICS AND CHARACTERISTICS OF AUDITED DEATHS
............................................ 20
6.5.
E
STABLISHING THE CAUSE OF DEATH
................................................................................ 21
6.6.
P
EER REVIEW PROCESS
.................................................................................................. 23
6.7.
7.
CLINICAL RISK MANAGEMENT.................................................................................................... 25
P
ROFILE OF OPERATIVE PROCEDURES
.............................................................................. 25
7.1.
C
LINICALLY SIGNIFICANT INFECTIONS
............................................................................... 34
7.2.
D
ELAY IN DIAGNOSIS
....................................................................................................... 36
7.3.
D
EEP VEIN THROMBOSIS PROPHYLAXIS
............................................................................ 37
7.4.
A
DEQUACY OF PROVISION OF CRITICAL CARE SUPPORT TO PATIENTS
................................. 41
7.5.
I
SSUES WITH FLUID BALANCE
........................................................................................... 43
7.6.
T
RAUMA
......................................................................................................................... 44
7.7.
P
ATIENT TRANSFER ISSUES
............................................................................................. 45
7.8.
O
UTCOMES OF THE PEER REVIEW
.................................................................................... 47
7.9.
8.
VASM EVALUATION ...................................................................................................................... 53
T
REATING SURGEON
’
S APPRAISAL OF THE
VASM
PEER REVIEW PROCESS
......................... 53
8.1.
VASM E
VALUATION
S
URVEY
........................................................................................... 53
8.2.
T
HE
P
ERCEIVED
Q
UALITY OF
VASM
I
NFORMATION
........................................................... 53
8.3.
C
ONCORDANT VALIDITY CONSIDERATIONS
........................................................................ 55
8.4.
9.
VASM EDUCATIONAL ACTIVITIES ............................................................................................... 56
10.
AUDIT LIMITATIONS AND DATA MANAGEMENT........................................................................ 57
C
ONCLUSION
...................................................................................................................
57
10.1.
11.
REFERENCES................................................................................................................................. 58
12.
ACKNOWLEDGMENTS .................................................................................................................. 61