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HCA 375 Week 4 Adverse Event Repor

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HCA375– Continuous Quality Monitoring and Accreditation

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 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:

o    Medication error

o    Patient falls

o    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 

 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

 

·         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.

Part Two: CQI Tool (Complete Part Two of the Adverse Event template)

Choose a CQI Tool that best suits your chosen Adverse Event from the following list:

·         Flowchart

·         Fishbone Diagram (Cause & Effect)

·         Pareto

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 theAdverse 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. 

 

 

 

 

 

 

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