Adverse Event Reporting

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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.

Waypoint Assignment Submission

The assignments in this course will be submi#ed to Waypoint. Please refer to the instruc!ons below to submit your assignment.

1. Click on the Assignment Submission bu#on below. The Waypoint "Student Dashboard" will open in a new browser window. 2. Browse for your assignment. 3. Click Upload. 4. Confirm that your assignment was successfully submi#ed by viewing the appropriate week's assignment tab in Waypoint.

For more detailed instruc!ons, refer to the Waypoint Tutorial .

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