Read Chapters 5, 6, and 7 in our textbook.  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 prepare a report for the CEO of the hospital that includes all system failures that contributed to the adverse event as well as create a CQI tool (i.e., Pareto, Fishbone, or Flowchart).  Part 1: Description of Adverse Event (Complete Part 1 of the Adverse Event Template) Medication error Patient falls Post-operative hemorrhage Completing the template: Adverse Event Identify the chosen event. Create a scenario based on your chosen event. Discuss the incident and what happened. Identify the health care professionals involved. Explain the health care professional’s role in the incident. Historical Background Discuss the prevalence of the adverse event including historical information (i.e., how often this type of event occurs and prevention methods used by the industry). Legal and Accrediting Agency Requirements Address legal ramifications and accreditation agency requirements regarding the adverse event. CQI Team and Communication Identify the CQI team members. Based on the members you chose: Explain how their role within the hospital would benefit your team in identifying and analyzing the cause of the adverse event. Discuss issues that could arise between the team members when attempting to develop an improvement plan. Describe the steps you would take as the CQI team lead to make sure that everyone is able to communicate their opinions and recommendations. Describe barriers or conflicts that could occur within your team regarding effective communication. Operational or Safety Processes Discuss at least two operational and safety processes that you would recommend to the team to avoid future events from occurring. Explain the rationale for your recommendations. Impact of Event Discuss the impact on the hospital if the events continue to occur. Discuss the impact to the patients if the events continue to occur. Part 2: Graph the Data (Complete Part 2 of the Adverse Event Template) Once you choose your adverse event, graph the data from the chart above. You will graph Column A and B against the chosen event (i.e., number of medication errors, number of patient falls, or number of post-operative hemorrhages). For example, if I were to choose medication errors, I would enter the details from column A, B, and C. Once your graph is complete, copy/paste it in the space indicated within the template. Include an analysis of the data within the spaces indicated in the template: Discuss the frequency of the adverse event as compared to the increase or decrease of patient discharges. Analyze the data (what is the data telling you?). Identify the possible factors, in your opinion, that could be attributed to the change. Part 3: Create the CQI tool (Complete Part 3 of the Adverse Event Template)   Choose one of the CQI Tools listed below that best aligns with your chosen Adverse Event. Each of the tools listed below are hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates examples of each type of tool. Fishbone (Cause and Effect) Diagram (Links to an external site.) Flowchart (Links to an external site.) Pareto Chart (Links to an external site.) Next, you will be responsible for creating the CQI Tool, completing the tool, taking a screenshot, and copying/pasting the screenshot into the space indicated within the Adverse Event Template. If you are unfamiliar with these tools, please refer to the recommended readings, specifically the Siriwardena (2009) article from Week 2, Using Quality Improvement Methods for Evaluating Health Care. Part 4: Future Prevention (ComPLETE PART 4 OF THE ADVERSE EVENT TEMPLATE) After describing the event in Part 1, using a Graph in Part 2 and CQI tool in Part 3, you will apply the PDSA model in Part 4 to summarize the process and steps that your team would recommend to the CEO to prevent this adverse event from reoccurring. Respond to the items in Part 4 of the template by including the following: Plan Identify the problem that caused the adverse event/ Identify your objective. Identify the team members that will assist in the development of a plan for improvement. Describe how you would communicate the plan to the stakeholders. Discuss the reasons for collecting the data associated with the chosen scenario. Identify where you will pilot the new plan of action. Identify who, what, or why for your pilot of the improvement plan. (When you implement any new plan of action in a hospital setting, you will do a pilot of the new plan in a small, targeted area or department. For example, if you chose medication errors, a group of patients will be on the same floor [e.g., medical unit, cardiac unit, etc.]. If you chose patient falls, the patients will have the same diagnosis [e.g., hip replacement, etc.]. If you chose post-operative hemorrhage, the patients will have the same type of surgical procedure [e.g., abdominal surgeries, etc.].) Do Develop three possible solutions to the problem. Select one of the possible solutions to implement in the pilot phase. Discuss the result of the pilot (create your own scenario). Explain in detail the methods utilized to communicate the improvement process to the area chosen for the pilot phase. Study Summarize the data collected. Discuss how you would measure whether the pilot solution was effective. List observations. Discuss any problems that may have occurred in your scenario. Discuss any communication issues. Compare your objective in the Plan phase to that of the actual pilot result. Discuss what needs to be revised in your improvement plan to meet your objective. Act Discuss your revised plan. Describe how you are going to implement the plan hospital-wide. Describe how you will continually monitor the improvement plan to ensure sustained success. Determine if one of the steps you are recommending would require a check and balance step. Discuss why it is necessary. (It is important to keep in mind that some processes require a system of checks and balances.)

This project is an evaluation design for the program, problem, or policy you selected. This week, begin pulling together the many elements of this project into an initial draft, or Draft Evaluation Design.Include the following in your Draft Evaluation Design:Describe the program, problem, or policy that you identified.Identify and explain your revised research question and variables to be used in your evaluation.Identify and explain the revised research/evaluation design to be used in your evaluation and how this design addresses issues of validity and reliability.Identify and explain the sampling design to be used in your evaluation and the anticipated size of your sample.Identify and explain the information/data needed for the evaluation. Explain how, specifically, this information will be collected (e.g., what secondary sources you will use and/or what data collection instrument you will use to collect the information). If you plan on using a survey, please include the survey in an appendix to your paper.Use at least 10 scholarly sources from the library that were published within the past five years to support your paper. Be sure to follow APA guidelines when citing your sources.The Draft Evaluation Design should be double-spaced and 13–15 pages in length, not including the cover and reference pages.Required ResourcesReadingsJohnson, G. (2014). Research methods for public administrators (3rd ed.). Armonk, NY: M. E. Sharpe.Chapter 11, “Qualitative Data Analysis” (pp. 162–170)Edin, K., & Pirog, M. A. (2014). Special symposium on qualitative and mixed-methods for policy analysis. Journal of Policy Analysis Management, 33(2), 345–349. Special Symposium on Qualitative and Mixed-Methods for Policy Analysis by Edin, K., & Pirog, M. A. in Journal of Policy Analysis and Management, 33(2), 345–349. Copyright 2014 by John Wiley & Sons – Journals. Reprinted by permission of John Wiley & Sons – Journals via the Copyright Clearance Center.Harding, D. J., Wyse, J. J. B., Dobson, C., & Morenoff, J. D. (2014). Making ends meet after prison. Journal of Policy Analysis Management, 33(2), 440–470.Making Ends Meet After Prison by Harding, D. J., Wyse, J. J. B., Dobson, C., & Morenoff, J. D. in Journal of Policy Analysis and Management, 33(2), 440–470. Copyright 2014 by John Wiley & Sons – Journals. Reprinted by permission of John Wiley & Sons – Journals via the Copyright Clearance Center.Randles, J. M. (2014). Partnering and parenting in poverty: A qualitative analysis of a relationship skills program for low-income, unmarried families. Journal of Policy Analysis Management, 33(2), 385–412.Partnering and Parenting in Poverty: A Qualitative Analysis of a Relationship Skills Program for Low-Income, Unmarried Families by Randles, J. M. in Journal of Policy Analysis and Management, 33(2), 385–412. Copyright 2014 by John Wiley & Sons – Journals. Reprinted by permission of John Wiley & Sons – Journals via the Copyright Clearance Center.Vaterlaus, J., & Higginbotham, B. (2011). Qualitative program evaluation methods. NCSU: Raleigh, NC. Retrieved from http://ncsu.edu/ffci/publications/2011/v16-n1-2011-spring/vaterlaus-higginbotham.php

Details:Prepare this assignment as a 1,500-1,750 word paper using the instructor feedback from the Topic 1, 2, and 3 assignments and the guidelines below.PICOT Statement Revise the PICOT statement you wrote in the Topic 1 assignment.The final PICOT statement will provide a framework for your capstone project (the project students must complete during their final course in the RN-BSN program of study).Research CritiquesIn the Topic 2 and Topic 3 assignments you completed a qualitative and quantitative research critique. Use the feedback you received from your instructor on these assignments to finalize the critical analysis of the study by making appropriate revisions.The completed analysis should connect to your identified practice problem of interest that is the basis for your PICOT statement.Refer to "Research Critique Guidelines." Questions under each heading should be addressed as a narrative in the structure of a formal paper.Proposed Evidence-Based Practice ChangeDiscuss the link between the PICOT statement, the research articles, and the nursing practice problem you identified. Include relevant details and supporting explanation and use that information to propose evidence-based practice changes.Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.