Emergency Department Mortality Review
Structured review form for emergency department death cases
Patient Age
*
Patient Sex
*
Male
Female
Other/Undisclosed
Date and Time of ED Presentation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Death
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Brief Clinical Summary
*
Primary Diagnoses
*
Major Interventions Performed
ED Disposition
*
Please Select
Died in ED
Transferred to ICU
Transferred to Ward
Other
Contributing Factors (select all that apply)
Delayed presentation
Diagnostic error
Treatment delay
System/process issue
None identified
Other
Reviewer Findings and Follow-up/Outcome
*
Submit Review
Should be Empty: