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 one of the

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 (pareto, fishbone, flowchart). You will be using the Adverse Event template document 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)

- Medication error
- Patient falls
- Post-operative hemorrhage
  - The number of Discharges indicates the total number of patients who have been admitted and discharged in the hospital
  - Using the data listed below for your selected adverse event only, analyze and describe what the data is telling you. Make sure to include the graph in your template document.
  - Data – Patient Safety Event for XYZ Hospital for the year 20XX through 20YY

	# of Discharges		# of Surgical Cases		# of Medication Errors		# of Patient Falls		# of Post Operative Hemorrhage
	20XX	20YY	20XX	20YY	20XX	20YY	20XX	20YY	20XX	20YY
Jan	1200	1400	200	240	300	350	38	35	1	3
Feb	1278	1450	213	250	289	370	42	40	1	2
Mar	1389	1540	250	300	300	385	37	45	3	2
Apr	1199	1800	200	245	289	412	36	65	2	3
May	900	1768	159	289	215	404	40	70	1	3
Jun	1000	1690	173	285	215	398	46	65	1	2
Jul	1200	1100	215	200	278	246	50	45	2	1
Aug	1239	978	240	158	301	241	53	40	2	3
Sep	1000	1089	198	200	275	215	48	51	3	2
Oct	789	978	150	248	241	251	38	52	2	1
Nov	980	1000	175	209	230	231	42	47	2	1
Dec	700	980	145	215	200	235	25	43	3	1

Note: The number of beds and operating rooms increased effective 1/1/20YY.

List the advent chosen and include background such as prevalence of the incident.
Describe the adverse event in detail. You can make-up the scenario on the event topic chosen from the list or you can research an actual story on one of the events and utilize it for this assignment.
List who was involved in the event and their role in the event.
List the stakeholders on your CQI team. Discuss the differences among the stakeholders that might cause issues when working as a CQI team. Include barriers to their communicating effectively as a team and the communication techniques/methods utilized to inform the organization’s staff of the adverse event improvement plan.
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 one of the professional organizations and/or accrediting agencies would utilize to measure compliance with the standard.
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: Graph & CQI Tool (Complete Part Two of the Adverse Event template)
Graph the data

For your selected adverse event, graph the data for the two years. Include the graph in your template document. Include an analysis of the data. Determine if the frequency is increasing or decreasing. What is the data telling you? What factors could be attributed to the change?

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 the Adverse Event template.

Part Three: Future Prevention (Complete Part Three of the Adverse Event template)
After describing the event in Part One, using a Graph and 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.

Paper requirements:
The Adverse Event template document one completed must be six to seven pages in length (excluding title and references pages) and should demonstrate understanding of the reading assignments, class discussions, your own research, and the application of new knowledge. Excluding your textbook and course readings include a minimum of four scholarly, peer-reviewed sources. Two of these sources and must have been published within the past five years. An APA formatted reference page is required. Your responses within the document provided must be substantive, and include complete sentences in paragraph format, including citations per APA format