Adverse Event Reporting

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 theAdverse Event templateto 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 theAdverse 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 theAdverse 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.