Adverse Event Reporting

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 8 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.
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

Sample Solution