HCA375� Continuous Quality Monitoring and Accreditation

Name: HCA375� Continuous Quality Monitoring and Accreditation
Brand: Ashford University
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Author: Julian Cooper

Healthcare quality management systems and accreditation processes

Julian Cooper

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Running Head: REPORTING 1
Adverse Event Reporting
HCA375– Continuous Quality Monitoring and Accreditation
Adverse Event Reporting
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 be preparing a report for the CEO of the hospital that includes all system failures that contributed
to the adverse event as well as utilizing a CQI tool. You will be using the Adverse Event template to complete the
three parts to the assignment. Note: If you have responded substantively to each of the content items within the
three parts of the assignment, the paper should be between six and seven pages.
Part One: Description of Adverse Event (Complete Part One of the Adverse Event template)
 Choose an adverse event from the following list:
o Medication error
o Patient falls
o Post-operative hemorrhage
 Data - Patient Safety Event For XYZ Hospital for 20XX through 20YY
# of Discharges # of Surgical Cases # of Medication Errors
20XX 20YY 20XX 20YY 20XX 20YY
Jan 1200 1400 200 240 300 350
Feb 1278 1450 213 250 289 370
Mar 1389 1540 250 300 300 385
Apr 1199 1800 200 245 289 412
May 900 1768 159 289 215 404
Jun 1000 1690 173 285 215 398
Jul 1200 1100 215 200 278 246
Aug 1239 978 240 158 301 241
Sep 1000 1089 198 200 275 215
Oct 789 978 150 248 241 251
Nov 980 1000 175 209 230 231
Dec 700 980 145 215 200 235
 Note: The number of beds and operating rooms increased effective 1/1/20YY.
 Describe the adverse event, including who was involved in the event.

REPORTING 2
 For your selected adverse event, graph the data for the two years. Analyze the data by determining if the frequency is
increasing 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 this
event to take place. For instance, describe any regulations or procedures that the professional organization and/or
accrediting 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 increasing
or 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 adverse
event.
 Describe how processes of continuous quality monitoring could impact the adverse event you chose.
Part Two: CQI Tool (Complete Part Two of the Adverse Event template)
Choose a CQI Tool that best suits your chosen Adverse Event from the following list:
 Flowchart
 Fishbone Diagram (Cause & Effect)
 Pareto
Use the CQI Tool to illustrate the use of the tool with your chosen adverse event. You will be responsible for creating
the CQI Tool, completing the tool, taking a screenshot, and copying/pasting the screenshot under the instructions in
Part Two CQI Tool in theAdverse Event template.
Part Three: Future Prevention (Complete Part Three of the Adverse Event template)
After describing the event in Part One and using a CQI tool in Part Two, apply the PDCA model to summarize the
process 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 the
Explanation 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 determine
if one of the steps you are recommending would require a checks and balance step and why it is necessary.

REPORTING 3
HCA375 - WEEK 4 ASSIGNMENT
PART 1 – DESCRIPTION OF ADVERSE EVENT
CONTENT DESCRIPTION
ADVERSE EVENT CHOSEN The adverse event chosen for 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 one medication error every day
for every inpatient (Binder, 2013, p. 1).” This issue is a large contributing factor
to low patient satisfaction as well as low-grade quality of care. If there is one
area that there is absolutely zero room for mistakes, it would be in the
medication management position of the hospital. It is impossible to prevent
medication errors from ever occurring, however, actions can be taken to see that
the frequency remains low. Proper communication, use of updated technological
systems, and staff coordination as well as up-to-date training are all tools that
can be used in order to prevent medication errors from occurring within the
facility.
DESCRIBE THE EVENT With great regret, on the 25th day of December 2014, a medication error
was made by a nurse in the pediatric section of our intensive care unit resulting
in the death of a 3 month old patient. The patient presented in our ICU wing for
services related to what should have been a routine surgical procedure. The
patient was given 60 times the normal dose of sodium through IV. This
medication error was discovered after a great length of time and also was not
addressed in a timely fashion; resulting in the death of our patient brought on
through cardiac arrest. The patient suffered an overdose of sodium and due to
the error in labeling of the medication as well as the poor monitoring of our floor
nurses, the preventable death of this patient occurred.

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Ashford University

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Healthcare

HCA375� Continuous Quality Monitoring and Accreditation

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