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 chos.

1. 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:

2. 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

3. # 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

4. 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

5. 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

6. 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

7. 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?
·

8. 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.

9. ·
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

10. 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 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.
Paper requirements:
The Paper 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

11. substantive, and include complete sentences in paragraph
format, including citations per APA format. Refer to the
Ashford Writing Center
for information on APA guidelines.