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:
◦ 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
• 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 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. 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.
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To complete the assignment, follow these step-by-step instructions:
Part One: Description of Adverse Event
1. Choose an adverse event from the provided list:
a. Medication error
b. Patient falls
c. Post-operative hemorrhage
2. Describe the chosen adverse event, including the individuals involved.
3. Utilize the provided data for the chosen adverse event and graph the data for the two years.
4. Analyze the data by determining whether the frequency is increasing or decreasing.
5. Identify factors that could be attributed to the change in frequency.
6. Discuss the communication techniques/methods utilized to inform the staff of the adverse event.
7. Describe at least two operational or safety processes that might not have been followed, contributing to or causing the event.
8. Graph the two years of data for the selected adverse event and analyze if the frequency is increasing or decreasing.
9. Explain the factors that could attribute to the change in data over two years.
10. Summarize the historical and contemporary issues and legal implications related to patient safety in the chosen adverse event.
11. Describe how the processes of continuous quality monitoring could impact the chosen adverse event.
Part Two: CQI Tool
1. Choose the most suitable CQI Tool for the chosen adverse event from the provided list:
a. Flowchart
b. Fishbone Diagram (Cause & Effect)
c. Pareto
2. Create the selected CQI Tool to illustrate its use with the chosen adverse event.
3. Complete the CQI Tool with relevant information.
4. Take a screenshot of the completed CQI Tool.
5. Copy and paste the screenshot into the designated section of Part Two in the Adverse Event template.
Part Three: Future Prevention
1. Apply the PDCA (Plan-Do-Check-Act) model to summarize the process and steps recommended to prevent the adverse event from reoccurring.
2. Include the healthcare personnel who would be accountable at each step of the process.
3. Determine if any of the recommended steps require a checks and balance system, and explain why it is necessary.
Paper Requirements:
1. Write a paper of six to seven pages in length (excluding title and references pages) adhering to APA guidelines.
2. Demonstrate understanding of the reading assignments, class discussions, and your own research.
3. Include a minimum of four scholarly, peer-reviewed sources (including at least two from the Ashford University Library published within the past five years).
4. Use complete sentences in paragraph format, providing citations per APA format.
Refer to the Ashford Writing Center for assistance with APA formatting guidelines.
To complete this assignment on adverse event reporting, you will need to follow the instructions given in the prompt. Here is a step-by-step guide on how to approach this assignment:
1. Start by reading Chapters 5, 6, and 7 in the textbook to gain a thorough understanding of adverse event reporting and risk management.
2. Choose one adverse event from the list provided: Medication error, Patient falls, or Post-operative hemorrhage.
3. Using the Adverse Event template provided, complete Part One by describing the chosen adverse event, including the individuals involved.
4. Graph the data provided for the selected adverse event from the given table, covering a two-year period. Analyze the data to determine if the frequency of the adverse event is increasing or decreasing. Identify any factors that could be attributed to the change in frequency.
5. Discuss the communication techniques/methods utilized to inform the staff of the adverse event. Consider how the organization effectively communicated the incident to ensure awareness and prevent future occurrences.
6. Describe at least two operational or safety processes that might not have been followed, contributing to the adverse event. Refer to any regulations or procedures required by professional organizations and accrediting agencies that were not followed, resulting in the event.
7. Graph two years of data for your selected adverse event and analyze the data to determine if the frequency is increasing or decreasing. Consider any factors or changes that could be influencing the trend in the adverse event occurrence over time.
8. Summarize the historical and contemporary issues and legal implications related to patient safety in your chosen adverse event. Briefly explain any significant events or legal cases related to the adverse event.
9. Describe how processes of continuous quality monitoring could impact the adverse event you chose. Explain how ongoing monitoring and evaluation of processes can help identify areas for improvement and prevent future adverse events.
10. For Part Two, choose a CQI (Continuous Quality Improvement) tool that best fits your chosen adverse event from the list provided: Flowchart, Fishbone Diagram (Cause & Effect), or Pareto. Create and complete the CQI tool, take a screenshot, and copy/paste it into the Adverse Event template.
11. For Part Three, apply the PDCA (Plan-Do-Check-Act) model to summarize the process and steps recommended by your team to prevent the chosen adverse event from reoccurring. Identify the healthcare personnel accountable at each step of the process and explain the importance of incorporating checks and balance steps, if necessary.
12. Write a paper that encompasses Parts One, Two, and Three of the Adverse Event template. Ensure the paper is between six and seven pages in length (excluding title and references pages).
13. Use at least four scholarly, peer-reviewed sources, two of which must be from the Ashford University Library and published within the past five years. Follow APA formatting guidelines for in-text citations and the reference page.
14. Proofread your paper to ensure proper grammar, spelling, and organization. Use the Grading Rubric to ensure you have met all the criteria for evaluation.
By following these steps, you should be able to complete the assignment on adverse event reporting successfully.