HCA375 Adverse Event Reporting: Continuous Quality Monitoring and Accreditation

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Running Head: REPORTING1Adverse Event ReportingHCA375–Continuous Quality Monitoring and AccreditationAdverse Event ReportingRead Chapters 5, 6, and 7 in our textbook. After reviewing this week’s required reading, consider the followingscenario: Youare the lead of the risk management team that has been assigned to evaluate an incident that hasoccurred. You will be preparing a report for the CEO of the hospital that includes all system failures that contributedto the adverse event as well as utilizing a CQI tool. You will be using theAdverse Event templateto complete thethree parts to the assignment. Note: If you have responded substantively to each of the content items within thethree 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 thefollowing list:oMedication erroroPatient fallsoPost-operative hemorrhageData-Patient Safety Event For XYZ Hospital for 20XX through 20YY# of Discharges# of Surgical Cases# of Medication Errors20XX20YY20XX20YY20XX20YYJan12001400200240300350Feb12781450213250289370Mar13891540250300300385Apr11991800200245289412May9001768159289215404Jun10001690173285215398Jul12001100215200278246Aug1239978240158301241Sep10001089198200275215Oct789978150248241251Nov9801000175209230231Dec700980145215200235

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REPORTING2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 isincreasing 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 thisevent to take place. For instance, describe any regulations or procedures that the professional organization and/oraccrediting 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 increasingor 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 adverseevent.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)ParetoUse the CQI Tool to illustrate the use of the tool with your chosen adverse event. You will be responsible for creatingthe CQI Tool, completing the tool, taking a screenshot, and copying/pasting the screenshot under the instructions inPart Two CQI Tool in theAdverse Event template.Part Three: Future Prevention(Complete Part Three of theAdverse Event template)After describing the event in Part One and using a CQI tool in Part Two, apply the PDCA model to summarize theprocess 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 theExplanation 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 determineif one of the steps you are recommending would require a checks and balance step and why it is necessary.

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REPORTING3HCA375-WEEK4ASSIGNMENTPART 1–DESCRIPTION OFADVERSEEVENTCONTENTDESCRIPTIONADVERSEEVENT CHOSENThe adverse event chosenfor this assignment is medication error.“Medication errors happen all the time, an estimated one million each year,contributing to 7,000 deaths. On average there is onemedication error every dayfor every inpatient (Binder, 2013, p. 1).”This issue is a large contributing factorto low patient satisfaction as well as low-grade quality of care. If there is onearea that there is absolutely zero room for mistakes, it would be in themedication management position of the hospital. Itisimpossible to preventmedicationerrors from ever occurring, however, actions can be taken to see thatthe frequency remains low.Proper communication, use of updated technologicalsystems, and staff coordinationas well asup-to-date training are all tools thatcan be used in order to prevent medication errors from occurring within thefacility.DESCRIBE THE EVENTWith great regret, on the 25thday of December 2014, a medication errorwas made by a nurse in the pediatric section of ourintensive care unit resultinginthe deathof a 3monthold patient.The patient presented in our ICU wing forservices related to what should have been a routine surgical procedure. Thepatient was given 60 times the normal dose ofsodium through IV. Thismedication error was discovered after a great length of time and also was notaddressed in a timely fashion;resulting in the death of our patientbrought onthrough cardiac arrest. The patient suffered an overdose of sodium and due tothe error in labeling of the medication as well as the poor monitoring of our floornurses, the preventable death of this patient occurred.

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