Adverse Event Reporting

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 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).
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 document should be between 8 to 10
pages.
Part 1: Description of Adverse Event

1. Medication error
2. Patient falls
3. Post-operative hemorrhage