Chapters 5, 6, and 7 in our textbook. After reviewing this week’s
required reading, consider the following scenario: You are the lead of
the risk management team that has been assigned to evaluate an incident
that has occurred. You will be preparing a report for the CEO of the
hospital that includes all system failures that contributed to the
adverse event as well as utilizing a CQI tool. You will be using the Adverse Event template to
complete the three parts to the assignment. Note: If you have responded
substantively to each of the content items within the three parts of
the assignment, the paper should be between six and seven pages.
Data - Patient Safety Event For XYZ Hospital for 20XX through 20YY
# of Discharges
# of Surgical Cases
# of Medication Errors
# of Patient Falls
# of Post Operative Hemorrhage
Note: The number of beds and operating rooms increased effective 1/1/20YY.
Describe the adverse event, including who was involved in the event.
your selected adverse event, graph the data for the two years. Analyze
the data by determining if the frequency is increasing or decreasing.
What factors could be attributed to the change?
Discuss the communication techniques/methods utilized to inform the staff of the adverse event.
at least two operational or safety processes that might not have been
followed that contributed or caused this event to take place. For
instance, describe any regulations or procedures that the professional
organization and/or accrediting agency measures compliance with the
Graph two years of data for your selected adverse
event and analyze the data by determining if the frequency is increasing
What factors could attribute to the change in data over two years?
Summarize the historical and contemporary issues and legal implications related to patient safety in your chosen adverse event.
Describe how processes of continuous quality monitoring could impact the adverse event you chose.
Choose a CQI Tool that best suits your chosen Adverse Event from the following list:
Fishbone Diagram (Cause & Effect)
the CQI Tool to illustrate the use of the tool with your chosen adverse
event. You will be responsible for creating the CQI Tool, completing
the tool, taking a screenshot, and copying/pasting the screenshot under
the instructions in Part Two CQI Tool in the Adverse Event template.
describing the event in Part One and using a CQI tool in Part Two,
apply the PDCA model to summarize the process and steps that your team
would recommend to the CEO to prevent this adverse event from
reoccurring. Make sure to include who (health care personnel) would be
accountable at each step of the process. Complete the Explanation column
in Part 3 of the Adverse Event template.
is important to keep in mind that some processes require a checks and
balance system. You will need to determine if one of the steps you are
recommending would require a checks and balance step and why it is
Paper must be six to seven pages in length (excluding title and
references pages) and should demonstrate understanding of the reading
assignments, class discussions, your own research, and the application
of new knowledge. Excluding your textbook and course readings include a
minimum of four scholarly, peer-reviewed sources. Two of these sources
must be from the Ashford University Library and must have been published
within the past five years. An APA formatted reference page is
required. Your responses within the document provided must be
substantive, and include complete sentences in paragraph format,
including citations per APA format. Refer to the Ashford Writing Center for information on APA guidelines.
Carefully review the Grading Rubric for the criteria that will be used to evaluate your assignment.