| Course | D913 Risk Management and Compliance |
|---|---|
| Task | Task 1 |
| Paper type | Adverse event corrective action plan |
| Length | About 1,100 words, 4 pages |
| Format | APA 7 |
| School | Western Governors University (WGU) |
| Program | Master of Healthcare Administration |
| Updated | September 2026 |
Free sample paper for D913 Task 1
Eight Hours From Fall to Scan: An Adverse Event Analysis, Survey Readiness Review and Corrective Action Plan After a Patient on Apixaban Fell at Night in a Composite Hospital
Student Name
Leavitt School of Health, Western Governors University
D913: Risk Management and Compliance, Task 1
Course Instructor
Month Day, Year
Eight Hours From Fall to Scan: An Adverse Event Analysis, Survey Readiness Review and Corrective Action Plan After a Patient on Apixaban Fell at Night in a Composite Hospital
The Event
Mrs. Helen Varga, a composite 81-year-old woman taking apixaban for atrial fibrillation, was admitted to the medical unit of Clearwater Regional Hospital, a composite 200-bed hospital, with pneumonia. At 2:10 a.m. on her third night she got up alone to use the bathroom, fell and struck her head on the floor. Her nurse found her within minutes, helped her back to bed and checked her vital signs and neurological status, which were normal. The nurse paged the overnight cross-cover physician, who did not know the patient, and reported a fall without apparent injury. The physician ordered neurological checks every four hours. No head imaging was ordered.
At 8:30 a.m., the day team found Mrs. Varga newly confused. A head CT at 10:05 a.m. showed a subdural hematoma. She received an anticoagulant reversal agent, was transferred to intensive care and was seen by neurosurgery. She survived, but instead of going home she left the hospital for a skilled nursing facility. Because the fall caused an intracranial hemorrhage requiring treatment, the hospital classified it as a sentinel event under its accreditation policy, which requires a comprehensive analysis and an action plan.
Analysis Method
A root cause analysis team of the unit manager, the night nurse, a hospitalist, a pharmacist, the patient safety officer and a risk manager reconstructed the night from the medical record, the nurse call and paging logs and interviews. The team used a fishbone diagram to organize causes into policy, communication, technology, people and environment, and asked why at each step until it reached causes the hospital could change. The analysis was deliberately framed around the system, not the individual nurse or physician.
Contributing and Root Causes
Policy was the root cause. Clearwater's post-fall policy, last revised in 2019, required a physician notification and neurological checks after every fall but left imaging to the physician's judgment, with no rule for patients taking anticoagulants. Research supports the concern: in a study of 934 falls on acute medical wards, anticoagulation and head strike were among the factors associated with intracranial hemorrhage, and fewer than 10% of patients received an urgent scan within one hour (Stephen et al., 2019).
Communication contributed. The nurse's page did not mention that Mrs. Varga was taking apixaban or that she had struck her head, because the hospital had no structured post-fall report. The cross-cover physician, responsible for more than 100 patients overnight, did not look up her medications.
Technology contributed. The EHR had no post-fall order set and no alert linking a documented fall to an active anticoagulant order. The hospital assesses fall risk with the Morse Fall Scale, whose six items cover prior falls, a second diagnosis, walking aids, an intravenous line, gait and mental status (Morse et al., 1989). It predicts who may fall, not who would be badly hurt by a fall, so it did not identify Mrs. Varga's high risk of injury.
Environment contributed. Her bed alarm had been turned off after she asked for it to be silenced, and the bathroom was across the room.
Survey Readiness
Accreditation standards expect hospitals to assess and manage patients' risk of falling and to respond to serious fall-related injuries with a thorough analysis and action. The Joint Commission has urged hospitals to use standardized, validated tools to assess fall and injury risk, to individualize interventions and to standardize post-fall management, including a structured assessment of injury (The Joint Commission, 2015). Federal Conditions of Participation also require hospitals to track adverse events, analyze their causes and implement preventive actions through their quality assessment and performance improvement program (42 C.F.R. ยง 482.21).
Measured against those expectations, Clearwater is not ready for a surveyor today. Its post-fall policy is outdated and silent on anticoagulated patients. Its fall assessment measures fall risk but not injury risk. It has no audit data showing how post-fall care is carried out. On the positive side, the event was reported promptly, the root cause analysis was started within 72 hours, and staff interviewed were candid, all evidence of a reporting culture a surveyor would look for. The corrective action plan below is designed to close the gaps and produce the evidence, such as revised policies, order set use and audit results, that a surveyor would ask to see.
Corrective Action Plan
Each action changes a system, has one owner and a completion date and is measured.
| Action | Owner | Due | Measure and target |
|---|---|---|---|
| Revise post-fall policy: any head strike or unwitnessed fall in a patient on an anticoagulant or antiplatelet drug requires a head CT within one hour and neurological checks every 15 minutes for the first hour | Chief medical officer with the hospitalist director | 30 days | Qualifying falls with CT within one hour; target 90% |
| Build an EHR post-fall order set and an alert when a fall is documented for a patient with an active anticoagulant order | Chief medical information officer | 60 days | Order set used for 95% of documented falls |
| Introduce a structured post-fall report that includes head strike and anticoagulant status | Director of nursing | 30 days | Monthly audit of 20 falls; all elements present in 90% |
| Add an injury risk flag for patients on anticoagulants, with low beds, floor mats and scheduled toileting | Falls prevention committee chair | 60 days | Flag and interventions present for 90% of eligible patients on audit |
| Add anticoagulant status to the evening physician handoff | Hospitalist director | 30 days | Handoff audit; 95% compliance |
Sustaining the Plan
The patient safety officer will report the measures monthly to the patient safety committee for six months and quarterly after that, alongside the unit's rate of injurious falls for every 1,000 days of patient care. If any measure falls below target for two consecutive months, the owner must present a corrective plan to the committee. The team will also conduct a mock survey tracer on the medical units at 90 days, following a patient on an anticoagulant through fall risk assessment, prevention and a simulated post-fall response, so that staff can show a surveyor the new process in practice. Mrs. Varga's family was told what happened and what the hospital is changing, consistent with the hospital's disclosure policy.
References
Morse, J. M., Morse, R. M., & Tylko, S. J. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8(4), 366-377. https://doi.org/10.1017/S0714980800008576
Stephen, S., Wong, E. W. W., Idris, A. M., & Lim, A. K. H. (2019). Intracranial haemorrhage detected by cerebral computed tomography after falls in hospital acute medical wards. BMC Health Services Research, 19, Article 792. https://doi.org/10.1186/s12913-019-4634-8
The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities (Sentinel Event Alert, Issue 55).
What the D913 Task 1 instructions ask
The first D913 task asks you to analyze an adverse event and plan how the organization will prevent recurrence and demonstrate compliance. You will usually describe the event, explain the analysis method, identify contributing and root causes, assess readiness for an accreditation survey, write a corrective action plan and describe how improvements will be sustained. The event may be supplied by the course. Graders want an analysis that moves past individual error to policy and systems, readiness judged against specific standards, actions that change systems rather than only retraining staff and a plan for sustaining results. A plan that disciplines the nurse and stops there falls short of the analysis aspects. Keep the event facts consistent throughout, since every later section depends on them.
How this D913 Task 1 example is built
The analysis opens with a factual account of the patient, the fall and the delay, in time order. The method section lists the team by role and the sources they used, such as the chart, call light records and interviews. Contributing causes are grouped by policy, communication and technology, and the root cause is stated as a system condition. The readiness section compares the hospital's current practice with accreditation expectations and names the gaps a surveyor would find. The corrective action plan is a table with actions, owners, dates and measures. The sustainment section explains reporting, escalation if measures slip and a mock tracer to test whether the changes hold. Sources include accreditation guidance and research on falls in anticoagulated patients.
Where the D913 Task 1 rubric puts the marks
D913 Task 1 aspects are scored competent, approaching competence or not evident. An event aspect looks for a factual description. A method aspect rewards a recognized analysis with the right team. A causes aspect asks for root and contributing causes at the system level. A survey readiness aspect wants gaps judged against standards. An action plan aspect looks for system changes with owners, dates and measures. A sustainment aspect asks how results will be monitored over time. Graders notice when stronger actions, such as order sets and automated alerts, outweigh reminders and training, and they expect accreditation and patient safety guidance cited wherever a requirement appears. Clear ownership of each action matters.
D913 Task 1 help: what sends it back
D913 plans are usually returned for one of five reasons. The root cause is a person; ask what let that person's decision cause harm. Survey readiness is a general statement; compare practice with the standard and list gaps. Actions are mostly education; add changes that make the safe path the easy one, such as an imaging order built into the post-fall order set. Measures count completed actions; measure the practice, such as the time from fall to scan. Sustainment ends when the plan is written; describe who reviews the measures, how often and what happens if they slip, because surveyors look for evidence that improvements lasted.
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D913 Task 1 questions, answered
Is the D913 event real?
No. Mrs. Varga and Clearwater Regional Hospital are invented for the sample. The accreditation expectations and research on falls in patients taking anticoagulants are real and cited in the paper.
Why is training alone weak in D913 Task 1?
Training depends on memory and fades with turnover. Actions that change systems, such as order sets, alerts and revised policy, keep working when staff change, which is why graders favor them.
What evidence shows survey readiness in D913?
Documented policies that match standards, audits showing practice follows them and records of the analysis and actions after a serious event. The sample adds a mock tracer to test readiness.
Who belongs on the D913 analysis team?
People who were involved and people who can change the system, such as the unit manager, the night nurse, a hospitalist, a pharmacist, the patient safety officer and a risk manager.
Where can I find a free D913 Task 1 sample paper?
The fall analysis and corrective action plan appear above with reviewer notes. Share the D913 event you were given, and the first custom plan costs you nothing.