Adverse Event Reporting

Please see attachments. Please use word document attached to fill in answers.

HCA375 Assignments Week 4 – Assignment!

Week 4 – Assignment

Due Monday by 11:59pm Points 16 Submi!ng an external tool

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Adverse Event Repor!ng
Read Chapters 5, 6, and 7 in our textbook. A”er 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 substan!vely to each of the content items within
the assignment document and included your graph of the data as well as the CQI tool illustra!on, the template document should be between eight to 10
pages.

Part 1: Descrip”on of Adverse Event (Complete Part 1 of the Adverse Event Template)

Medica!on error
Pa!ent falls
Post-opera!ve hemorrhage

Comple!ng the template:

Adverse Event
Iden!fy the chosen event.
Create a scenario based on your chosen event.
Discuss the incident and what happened.
Iden!fy 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 informa!on (i.e., how o”en this type of event occurs and preven!on methods used
by the industry).

Legal and Accredi!ng Agency Requirements
Address legal ramifica!ons and accredita!on agency requirements regarding the adverse event.

CQI Team and Communica!on
Iden!fy the CQI team members. Based on the members you chose:

Explain how their role within the hospital would benefit your team in iden!fying and analyzing the cause of the adverse event.
Discuss issues that could arise between the team members when a#emp!ng 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 recommenda!ons.
Describe barriers or conflicts that could occur within your team regarding effec!ve communica!on.

Opera!onal or Safety Processes
Discuss at least two opera!onal and safety processes that you would recommend to the team to avoid future events from occurring.
Explain the ra!onale for your recommenda!ons.

Impact of Event
Discuss the impact on the hospital if the events con!nue to occur.
Discuss the impact to the pa!ents if the events con!nue to occur.

Note: The number of beds and opera!ng 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
medica!on errors, number of pa!ent falls, or number of post-opera!ve hemorrhages). For example, if I were to choose medica!on 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 pa!ent discharges.
Analyze the data (what is the data telling you?).
Iden!fy the possible factors, in your opinion, that could be a#ributed 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
Ins!tute for Health Care Improvement website, which discusses and illustrates examples of each type of tool.

Fishbone (Cause and Effect) Diagram
Flowchart
Pareto Chart

Next, you will be responsible for crea!ng the CQI Tool, comple!ng the tool, taking a screenshot, and copying/pas!ng 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) ar!cle from Week 2, Using
Quality Improvement Methods for Evalua!ng Health Care.

Part 4: Future Preven”on (Complete Part 4 of the Adverse Event Template)

A”er 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

Iden!fy the problem that caused the adverse event/
Iden!fy your objec!ve.
Iden!fy 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 collec!ng the data associated with the chosen scenario.
Iden!fy where you will pilot the new plan of ac!on.
Iden!fy who, what, or why for your pilot of the improvement plan. (When you implement any new plan of ac!on in a hospital se%ng, you will
do a pilot of the new plan in a small, targeted area or department. For example, if you chose medica!on errors, a group of pa!ents will be on
the same floor [e.g., medical unit, cardiac unit, etc.]. If you chose pa!ent falls, the pa!ents will have the same diagnosis [e.g., hip replacement,
etc.]. If you chose post-opera!ve hemorrhage, the pa!ents will have the same type of surgical procedure [e.g., abdominal surgeries, etc.].)

Do
Develop three possible solu!ons to the problem.
Select one of the possible solu!ons to implement in the pilot phase.
Discuss the result of the pilot (create your own scenario).
Explain in detail the methods u!lized 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 solu!on was effec!ve.
List observa!ons.
Discuss any problems that may have occurred in your scenario.
Discuss any communica!on issues.
Compare your objec!ve in the Plan phase to that of the actual pilot result.
Discuss what needs to be revised in your improvement plan to meet your objec!ve.

Act
Discuss your revised plan.
Describe how you are going to implement the plan hospital-wide.
Describe how you will con!nually 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 applica!on of new knowledge.
Must have substan!ve responses within the template and include complete sentences in paragraph format, including cita!ons for each reference
listed. Refer to the Ashford Wri!ng Center for informa!on on APA guidelines.
Must demonstrate understanding of the reading assignments, class discussions, your own research, and the applica!on of new knowledge. Two of
your four sources must be from the Ashford University Library and must have been published within the past five years.

The Adverse Event Repor!ng paper, in the template,

Must be eight to 10 double-spaced pages in length (not including !tle and references pages) and forma#ed according to APA style as outlined in the
Ashford Wri!ng Center .
Must include a separate !tle page with the following:

Title of paper
Student’s name
Course name and number
Instructor’s name
Date submi#ed

Must use at least four scholarly sources in addi!on to the course text.
The Scholarly, Peer Reviewed, and Other Credible Sources table offers addi!onal guidance on appropriate source types. If you have ques!ons
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 par!cular assignment.

Must document all sources in APA style as outlined in the Ashford Wri!ng Center.
Must include a separate references page that is forma#ed according to APA style as outlined in the Ashford Wri!ng Center.

Carefully review the Grading Rubric for the criteria that will be used to evaluate your assignment.

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Titleof Paper

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HCA375– Continuous Quality Monitoring and Accreditation

Type Instructor Name Here

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HCA375 – WEEK 4 ASSIGNMENT

PART 1 – DETAIL OF THE ADVERSE EVENT CHOSEN

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 according to the

Ashford Writing Center

guidelines on the last page of this template.

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

WEEK 4 ASSIGNMENT

PART 2 – GRAPH THE DATA

You are tasked with graphing the data in Excel for your chosen event. The data is located in the classroom under the Week 4 Assignment Directions. Make sure to use only the data for your chosen event. The directions identify which columns of information to use depending on the chosen adverse event. Once you complete the graph in Excel, copy/paste your graph below.

Include an analysis of the data in paragraph format.

Discuss the frequency of the adverse event as compared to the increase or decrease of patient discharges.

What is the data telling you?

What possible factors in your opinion could be attributed to the change?

WEEK 4 ASSIGNMENT

PART 3 – CQI TOOL

· Choose one of the CQI Tools listed below 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 into the space below. If you are unfamiliar with these tools, please refer to the recommended readings, specifically the article from Week 2, which is listed below. You can locate the article in the Ashford Library.

· In addition, as a learning resource, the CQI tools listed below are hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates examples of each type of tool.

Siriwardena, A. (2009). Using quality improvement methods for evaluating health care. Quality in Primary Care, 17(3), 155-159. ISSN: 1479-1072 PMID: 19622265

· Choose a CQI Tool that best suits your chosen Adverse Event from the following list.

·

Fishbone (Cause and Effect) Diagram

·

Flowchart

·

Pareto Diagram

WEEK 4 ASSIGNMENT

PART 4 – FUTURE PREVENTION

APPLYING PDSA – Worksheet

PHASE	PHASE ACTIVITIES	EXPLANATION
PLAN	Problem Objective Team members Communication Data collected Pilot phase
DO	Three possible solutions One solution to implement Result of pilot (create own scenario) Methods of communication
STUDY	Summarize data Observations and problems Comparison of pilot plan to pilot results Revisions needed to meet objective
ACT	Revised improvement plan How to Implement the plan hospital wide Plan for monitoring the improvement plan Checks and balance

References

Excluding your textbook or course readings include at least four scholarly sources in addition to the course text. The sources should be peer-reviewed sources; that were published within the past five years. All references must be cited within the rows where the referenced material was used to support your ideas. The citations and references must be in APA format per the 6th edition guidelines, which can be found at the
Ashford Writing Center
.

These examples are correctly-formatted references. Note that they are in alphabetical order. You may NOT use these examples as your sources.