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 (pareto, fishbone, flowchart). You will be using the Adverse Event template document 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)
|# of Discharges||# of Surgical Cases||# of Medication Errors||# of Patient Falls||# of Post Operative Hemorrhage|
Note: The number of beds and operating rooms increased effective 1/1/20YY.
Part Two: Graph & CQI Tool (Complete Part Two of the Adverse Event template)
Graph the data
Choose a CQI Tool that best suits your chosen Adverse Event from the following list:
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, using a Graph and 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.
The Adverse Event template document one completed 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
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