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 prepare a report for the CEO of the
hospital that includes all system failures that contributed to the
adverse event as well as create a CQI tool (i.e., Pareto, Fishbone, or
Flowchart). You are required to download and use the Adverse Event Template
document to complete the assignment. Note: If you have responded
substantively to each of the content items within the assignment
document and included your graph of the data as well as the CQI tool
illustration, the template document should be between eight to 10 pages.

Part 1: Description of Adverse Event (Complete Part 1 of the Adverse Event Template) FOUND BELOW

• Medication error
• Patient falls
• Post-operative hemorrhage

Completing the template:

• Adverse Event
  • Identify the chosen event.
  • Create a scenario based on your chosen event.
  • Discuss the incident and what happened.
  • Identify the health care professionals involved.
  • Explain the health care professional’s role in the incident.
• Historical Background
  • Discuss the prevalence of the adverse event including historical
    information (i.e., how often this type of event occurs and prevention
    methods used by the industry).
• Legal and Accrediting Agency Requirements
  • Address legal ramifications and accreditation agency requirements regarding the adverse event.
• CQI Team and Communication
  • Identify the CQI team members. Based on the members you chose:
    • Explain how their role within the hospital would benefit your team in identifying and analyzing the cause of the adverse event.
    • Discuss issues that could arise between the team members when attempting to develop an improvement plan.
  • Describe the steps you would take as the CQI team lead to make sure
    that everyone is able to communicate their opinions and recommendations.
  • Describe barriers or conflicts that could occur within your team regarding effective communication.
• Operational or Safety Processes
  • Discuss at least two operational and safety processes that you would
    recommend to the team to avoid future events from occurring.
  • Explain the rationale for your recommendations.
• Impact of Event
  • Discuss the impact on the hospital if the events continue to occur.
  • Discuss the impact to the patients if the events continue to occur.

Note: The number of beds and operating rooms increased from 2017 to 2018.

Part 2: Graph the Data (Complete Part 2 of the Adverse Event Template)

• Once you choose your adverse event, graph the data from the chart
  above. You will graph Column A and B against the chosen event (i.e.,
  number of medication errors, number of patient falls, or number of
  post-operative hemorrhages). For example, if I were to choose medication
  errors, I would enter the details from column A, B, and C. Once your
  graph is complete, copy/paste it in the space indicated within the
  template.
• Include an analysis of the data within the spaces indicated in the template:
  • Discuss the frequency of the adverse event as compared to the increase or decrease of patient discharges.
  • Analyze the data (what is the data telling you?).
  • Identify the possible factors, in your opinion, that could be attributed to the change.

Part 3: Create the CQI tool (Complete Part 3 of the Adverse Event Template)

• Choose one of the CQI Tools listed below that best aligns with your
  chosen Adverse Event. Each of the tools listed below are hyperlinked to
  the Institute for Health Care Improvement website, which discusses and
  illustrates examples of each type of tool.
  • Fishbone (Cause and Effect) Diagram (Links to an external site.)Links to an external site.
  • Flowchart (Links to an external site.)Links to an external site.
  • Pareto Chart (Links to an external site.)Links to an external site.
• Next, you will be responsible for creating the CQI Tool, completing
  the tool, taking a screenshot, and copying/pasting the screenshot into
  the space indicated within the Adverse Event Template.
  • If you are unfamiliar with these tools, please refer to the
    recommended readings, specifically the Siriwardena (2009) article from
    Week 2, Using Quality Improvement Methods for Evaluating Health Care.

Part 4: Future Prevention (Complete Part 4 of the Adverse Event Template)

After describing the event in Part 1, using a Graph in Part 2 and CQI
tool in Part 3, you will apply the PDSA model in Part 4 to summarize
the process and steps that your team would recommend to the CEO to
prevent this adverse event from reoccurring.

• Respond to the items in Part 4 of the template by including the following:
  • Plan
    • Identify the problem that caused the adverse event/
    • Identify your objective.
    • Identify the team members that will assist in the development of a plan for improvement.
    • Describe how you would communicate the plan to the stakeholders.
    • Discuss the reasons for collecting the data associated with the chosen scenario.
    • Identify where you will pilot the new plan of action.
    • Identify who, what, or why for your pilot of the improvement plan.
      (When you implement any new plan of action in a hospital setting, you
      will do a pilot of the new plan in a small, targeted area or department.
      For example, if you chose medication errors, a group of patients will
      be on the same floor [e.g., medical unit, cardiac unit, etc.]. If you
      chose patient falls, the patients will have the same diagnosis [e.g.,
      hip replacement, etc.]. If you chose post-operative hemorrhage, the
      patients will have the same type of surgical procedure [e.g., abdominal
      surgeries, etc.].)
  • Do
    • Develop three possible solutions to the problem.
    • Select one of the possible solutions to implement in the pilot phase.
    • Discuss the result of the pilot (create your own scenario).
    • Explain in detail the methods utilized to communicate the improvement process to the area chosen for the pilot phase.
  • Study
    • Summarize the data collected.
    • Discuss how you would measure whether the pilot solution was effective.
    • List observations.
    • Discuss any problems that may have occurred in your scenario.
    • Discuss any communication issues.
    • Compare your objective in the Plan phase to that of the actual pilot result.
    • Discuss what needs to be revised in your improvement plan to meet your objective.
  • Act
    • Discuss your revised plan.
    • Describe how you are going to implement the plan hospital-wide.
    • Describe how you will continually monitor the improvement plan to ensure sustained success.
    • Determine if one of the steps you are recommending would require a check and balance step.
      • Discuss why it is necessary. (It is important to keep in mind that some processes require a system of checks and balances.)

Paper Requirements:

The Adverse Event Template document, once completed,

• Should demonstrate an understanding of the reading assignments,
  class discussions, your own research, and the application of new
  knowledge.
• Must have substantive responses within the template and include
  complete sentences in paragraph format, including citations for each
  reference listed.
• Must demonstrate understanding of the reading assignments, class
  discussions, your own research, and the application of new knowledge.
  Two of your four sources must be from the University Library and
  must have been published within the past five years.

The Adverse Event Reporting paper, in the template,

• Must be eight to 10 double-spaced pages in length (not including
  title and references pages) and formatted according to APA style
• Must include a separate title page with the following:
  • Title of paper
  • Student’s name
  • Course name and number
  • Instructor’s name
  • Date submitted
• Must use at least four scholarly sources in addition to the course text.
  • The Scholarly, Peer Reviewed, and Other Credible Sources (Links to an external site.)Links to an external site.
    table offers additional guidance on appropriate source types. If you
    have questions about whether a specific source is appropriate for this
    assignment, please contact your instructor. Your instructor has the
    final say about the appropriateness of a specific source for a
    particular assignment.
• Must document all sources in APA style
• Must include a separate references page that is formatted according to APA style
• 
  

  CONTENT	DESCRIPTION
  ADVERSE EVENT
  HISTORICAL BACKGROUND
  LEGAL & ACCREDITING AGENCY REQUIREMENTS
  CQI TEAM COMMUNICATION
  OPERATIONAL OR SAFETY PROCESSES
  IMPACT OF THIS EVENT

  Refer to the instructions in the Week 4 Assignment
  of your online course to understand what is expected in each row. This completed template should be between eight
  to ten pages in length. Include APA citations
  within the description row where appropriate. List your references in APA
  format.
  PART 1 – DETAIL OF THE ADVERSE EVENT
  CHOSEN
  HCA375 – WEEK 4 ASSIGNMENT