alth Care Administration Assignment: Adverse Event Reporting
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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 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:
Medication error
Patient falls
Post-operative hemorrhage
Data - Patient Safety Event For XYZ Hospital for 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.
Describe the adverse event, including who was involved in the event.
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 the Adverse 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. Paper Requirements: The Paper 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 must be from the Ashford University Library 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. Refer to the Ashford Writing Center for information on APA guidelines.
b) Hire individuals “blindly” from the hiring pools which should eventually result in the proportion of X’s in your workforce more closely matching their representation in the pools of qualified applicants;
c) Hire individuals “randomly” from the hiring pools but give X’s an increased chance of being hired by raising the hiring pool percentage by 15% (i.e. is if 30% of the hiring pool is X, then hire giving X’s a 45% chance).
Strategy a) might be considered to “X biased” and is probably illegal; Strategy b) might be considered “neutral” and is probably legal; and Strategy c) might be considered “Pro X” and of unknown legal status.
Assignment:
Your job is to simulate the attrition and subsequent hiring on a yearly basis for a five year period for the above three strategies. In addition to showing the details of your simulation, you should also show a year by year summary of the workforce compositions of the three job categories by strategy. Further you should write a summary report assessing the effectiveness of the three strategies in the different job categories with respect to your objective of increasing the number of X’s in your workforce.
Hints:
1) Assume that adequate representation in your workforce is achieved when the percentage of X’s in the workforce matches the percentage representation in the appropriate hiring pools. This means that for Strategy a), even though biased toward X, if you achieve your goal you will hire only as many X’s as the number that leave. You have no control on the number of X’s with strategies b) and c).
2) You can assume that all simulated probability distributions are independent of one another and that the total size of the workforce in each category will remain the same over the five year period.
3) Use the Poisson distribution to simulate total attrition for each job category for each of the five years. These total attrition rates should be the same for all three strategies.
4) Assume that the attrition is “blind” to whether a person is X or not X. Accordingly you will have to determine how many of the people leaving will be X’s or not X’s. This will vary from year to year since the composition of the workforce will change over time. In addition, it will vary with the strategy since if the strategy results in a workforce with more X’s, then more X’s will leave. Simulate this with the Binomial distribution.
5) Replace the individuals who have left. In the case of Strategy a), this is done on a de facto “quota” basis. In the case of Strategies b) and c) use the Binomial distribution to determine how many new X employees are hired.
Table 1.
Workforce Starting Composition
Category # X # not X Total Turnover Rate
Executive/Managerial 5 25 30 3% per Year
Professional 45 105 150 12% per Year
Clerical 120 180 300 25% per Year
Table 2.
Qualified Applicants for Position in Category
Category X Not X
Executive/Managerial 30% 70%
Professional 40% 60%
Clerical 50% 50%
This question was answered on: Sep 21, 2023
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