Adverse Event Management

After being admitted a medication, 25 years old male experience extreme nausea and vomiting which resulted in a prolong stay in the hospital. On initial investigation it appeared the original order was for three times the recommended dose.

Write a  creative& realistic thinking of this case by answering the questions and creating skillful points and scheduled as needed.


1. Adverse Event Type
a. Sentinel
b. Adverse
i. Mild Harm
ii. Moderate ? Severe Harm
c. Near Miss
1. Classification by Causes
a. Omission
b. Commission
c. Traditional

2. Write a Combine shared Vision and Need statement
a. Brainstorm on Opportunities and Threats prevent
i. What are the consequences if you do not prevent these events?
ii. What are the benefits if you prevented these events?
b. Vision Statement:
i. Is the vision motivating and energizing?
ii. What are the things you want the improvement to be known for patients?
iii. What are the words which describe what your patients would see, hear, or feel if the prevention efforts are successful.

c. Need Statement:
i. Who are the key stakeholders affected by this initiative, and how much importance dose each give to the initiative?
ii. Have we framed the need for change in such a way to reflect the concerns of patients and stakeholders?
iii. Would each team member deliver essentially the same message regarding the need for the change if asked by someone outside of the team?
iv. Why must you prevent these events?


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