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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)
- 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.
- Identify the CQI team members. Based on the members you chose:
- 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.
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.
- 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:
- 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.].)
- 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.
- 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.
- 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.)