Paper Requirements:
Part 1: Description of Adverse Event
Medication error
Use attached template for reference, use resources Chpt 5,6 & 7 attachments, APA format, 4 source references. 6 pg not including cover pg or reference
Adverse Event
o Identify the chosen event.
o Create a scenario based on your chosen event.
o Discuss the incident and what happened.
o Identify the health care professionals involved.
o Explain the health care professionals role in the incident.
Historical Background
o 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
o Address legal ramifications and accreditation agency requirements regarding the adverse event.
CQI Team and Communication
o 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.
o Describe the steps you would take as the CQI team lead to make sure that everyone is able to communicate their opinions and recommendations.
o Describe barriers or conflicts that could occur within your team regarding effective communication.
Operational or Safety Processes
o Discuss at least two operational and safety processes that you would recommend to the team to avoid future events from occurring.
o Explain the rationale for your recommendations.
Impact of Event
o Discuss the impact on the hospital if the events continue to occur.
o Discuss the impact to the patients if the events continue to occur.
Part 2: Graph the Data (Complete Part 2 Once you choose your adverse event, graph the data from the chart. 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 you were to choose medication errors, you would enter the details from column A, B, and C. Once your graph is complete, right click over the graph to copy it, then paste it in the space indicated within the template.
Include an analysis of the data within the spaces indicated in the template:
o Discuss the frequency of the adverse event as compared to the increase or decrease of patient discharges.
o Analyze the data (what is the data telling you?).
o Identify the possible factors, in your opinion, that could be attributed to the change.
Part 3: Create the CQI tool (Complete Part
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.
o Fishbone (Cause and Effect) Diagram (Links to an external site.)
o Flowchart (Links to an external site.)
o Pareto Chart (Links to an external site.)
Next, you will be responsible for creating the CQI Tool, completing the tool, taking a screenshot, and copying/pasting the screenshot into the space
o 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
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:
o Plan
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.].
o Do
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.
o Study
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.
o Act
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
