HCA375 Week 4 - Assignment
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Adverse Event Reporting
Read 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 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). You are required to download and use the Adverse Event Template document to complete the assignment. Note: If you have responded substantively to each of the content items within the assignment document and included your graph of the data as well as the CQI tool illustration, the template document should be between eight to 10 pages.
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.
Note: The number of beds and operating rooms increased from 2017 to 2018.
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.
- 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.