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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
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 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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