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Cover Page

1

Contents

3

Figures

4

Tables

5

Abbreviations

6

Clinical Directors Report

7

Mr Barry Beiles MB.BCh

8

Executive Summary

9

Participation Status

10

Recommendations

11

Infection Control

12

Introduction

13

The Audit Process

14

Audit Participation

15

Verification of Audit Numbers

16

Audit Participation Rates

17

The RANZCOG Board

18

Surgeon Agreement

19

Cases by Specialty

20

Hospital Clinical Governance

21

Demographics

22

Establishing the Cause of Death

23

Comments

24

Peer Review Process

25

Comments

26

Clinical Risk Management

27

Operative Mortality Frequency

28

Seniority of Surgeons

29

Timing of Operative Procedures

30

Unplanned Return

31

Seniority of Consultants

32

Postoperative Complications

33

Frequency of Specific

34

Postoperative Complications

35

Clinically Significant Infections

36

Comments

37

Delay in Diagnosis

38

Deep Vein Thrombosis

39

Type of DVT Prophylaxis Used

40

Reasons Given

41

Assessors Were Asked

42

Adequacy of Provision

43

Provision of Critical Care

44

Issues With Fluid Balance

45

Trauma

46

Patient Transfer Issues

47

Transfer Delays by Region

48

Outcomes of The Peer Review

49

Areas of Clinical Incidents

50

Comments

51

Frequency

52

Trends in Top Five

53

Shows The Frequency

54

VASM Evaluation

55

A Number of Themes Emerged

56

Concordant Validity

57

VASM Educational

58

Audit Limitations

59

References

60

Pham C Gibb C

61

Rural Doctors Association

62

Acknowledgments

63

VASM Management

64

Last Page

66