Adverse Event Reporting (I would like to use medication Error)
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.
Part One: Description of Adverse Event (Complete Part One of the Adverse Event template)
- Choose an adverse event from the following list:
- Medication error
- Patient falls
- Post-operative hemorrhage
- 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 |
| || 20XX|| 20YY|| 20XX|| 20YY|| 20XX|| 20YY|| 20XX|| 20YY|| 20XX|| 20YY|
|Jan || 1200||1400 ||200 || 240|| 300|| 350||38 ||35 ||1 ||3 |
| Feb|| 1278|| 1450|| 213|| 250|| 289|| 370|| 42|| 40|| 1|| 2|
| Mar|| 1389|| 1540|| 250|| 300|| 300|| 385|| 37|| 45|| 3|| 2|
| Apr|| 1199|| 1800|| 200|| 245|| 289|| 412|| 36|| 65|| 2|| 3|
| May|| 900|| 1768|| 159|| 289|| 215|| 404|| 40|| 70|| 1|| 3|
| Jun|| 1000|| 1690|| 173|| 285|| 215|| 398|| 46|| 65|| 1|| 2|
| Jul|| 1200|| 1100|| 215|| 200|| 278|| 246|| 50|| 45|| 2|| 1|
| Aug|| 1239|| 978|| 240|| 158|| 301|| 241|| 53|| 40|| 2|| 3|
| Sep|| 1000|| 1089|| 198|| 200|| 275|| 215|| 48|| 51|| 3|| 2|
| Oct|| 789|| 978|| 150|| 248|| 241|| 251|| 38|| 52|| 2|| 1|
| Nov|| 980|| 1000|| 175|| 209|| 230|| 231|| 42|| 47|| 2|| 1|
| Dec|| 700|| 980|| 145|| 215|| 200|| 235|| 25|| 43|| 3|| 1|
Part Two: CQI Tool
- Note: The number of beds and operating rooms increased effective 1/1/20YY.
- Describe the adverse event, including who was involved in the event.
- For 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.
- Describe 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 standard.
- Graph two years of data for your selected adverse event and analyze the data by determining if the frequency is increasing or decreasing.
- 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.
(Complete Part Two of the Adverse Event template
Choose a CQI Tool that best suits your chosen Adverse Event from the following list:
- Fishbone Diagram (Cause & Effect)
Use 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
.Part Three: Future Prevention
(Complete Part Three of the Adverse Event template
After 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.
It 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 necessary. Paper Requirements:
The 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. 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.
Carefully review the Grading Rubric
for the criteria that will be used to evaluate your assignment.