| Course | HC 405 Healthcare Quality |
|---|---|
| Unit | Unit 5 |
| Paper type | Incident trend summary |
| Length | About 950 words, 6 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | BS in Healthcare Administration |
| Updated | October 2026 |
Free sample paper for HC 405 Unit 5
Vascular Access Events Up From 11 to 18 a Quarter: An Incident Trend Summary for Gulfview Kidney Center's 2025 Reports, Split by Whether the Event Reached a Patient
Student Name
Health Care Administration, Herzing University
HC 405: Healthcare Quality
Instructor Name
February 12, 2026
Vascular Access Events Up From 11 to 18 a Quarter: An Incident Trend Summary for Gulfview Kidney Center's 2025 Reports, Split by Whether the Event Reached a Patient
What Was Counted
The summary covers every event report filed at Gulfview Kidney Center, the composite 24-chair outpatient dialysis facility, from January 1 to December 31, 2025, grouped into four calendar quarters of equal length. Reports were sorted into six operational categories, each owned by a different part of the team: vascular access events, such as needle infiltration, needle dislodgement and prolonged bleeding after needle removal; medication events; equipment and water system events; falls; documentation events; and behavior events, meaning aggression or threats by or toward patients or visitors. Each category is split into events that reached a patient and events caught before they did. In 2025 the center treated about 132 patients a quarter and delivered about 5,100 treatments a quarter, a volume that did not change materially during the year, so raw counts can be compared across quarters.
The Table
Each cell shows events that reached a patient, then events caught before reaching a patient.
| Category | Q1 | Q2 | Q3 | Q4 | Year total |
|---|---|---|---|---|---|
| Vascular access | 9 / 2 | 11 / 3 | 13 / 2 | 15 / 3 | 58 |
| Medication | 2 / 6 | 3 / 5 | 2 / 7 | 3 / 8 | 36 |
| Equipment and water system | 0 / 5 | 1 / 4 | 0 / 6 | 0 / 5 | 21 |
| Falls | 3 / 1 | 2 / 2 | 4 / 1 | 3 / 2 | 18 |
| Documentation | 0 / 4 | 0 / 3 | 0 / 5 | 0 / 4 | 16 |
| Behavior | 2 / 0 | 3 / 0 | 1 / 0 | 4 / 0 | 10 |
| All categories | 34 | 37 | 41 | 47 | 159 |
The Ordered Chart
Ordered from largest to smallest for the year, the categories form a sharply stepped chart: vascular access 58, medication 36, equipment and water 21, falls 18, documentation 16, behavior 10. Vascular access and medication together account for 94 of 159 reports, 59%. Vascular access alone accounts for 36%, and 48 of its 58 events reached a patient, the highest share of any category apart from behavior.
Reading the Table
Vascular access events rose every quarter, from 11 to 18, and the rise is almost entirely in events that reached patients, from 9 to 15. With stable treatment volume, that is unlikely to be a reporting artifact. The reports show that 35 of the 58 occurred during the second shift, and 31 within 20 minutes of a treatment starting or ending, when staff are connecting and disconnecting several patients at once and the next shift is waiting. That pattern matches published work from dialysis facilities, in which about 70% of errors occurred immediately before or after the treatment itself (Gu et al., 2014). It also matches the late starts and crowded changeovers identified earlier in this course.
Medication reports rose from 8 to 11, but the rise is in events caught before reaching a patient, from 6 to 8, while events that reached patients stayed at two or three a quarter. After a staff education session on reporting near misses in the second quarter, this pattern more likely reflects more reporting than more errors. It is a good sign rather than a warning.
Equipment and water system events were caught before reaching a patient in 20 of 21 cases, which suggests the monitoring and alarm defenses on machines and the water treatment system are working. Falls were steady at four or five a quarter, most in the parking lot or at the scale, and deserve attention but show no trend. Documentation events never reach a patient by their nature. Behavior events rose in the fourth quarter, all related to waiting times on the second shift, which again points to the same problem.
Rates and Harm
Because treatment volume was stable, counts and rates tell the same story, but the rate is the figure the quality committee should track going forward, since volume will change when the center adds chairs. Vascular access events per 1,000 treatments rose from about 2.2 in the first quarter to 2.7, 2.9 and then 3.5 in the fourth. If volume grows, a rising count would not by itself mean a worsening process, and a falling count might hide one; the rate removes that confusion.
The reports also record how much harm resulted. Of the 48 vascular access events that reached a patient, 39 caused a hematoma or bleeding controlled at the chair, which is minor harm; 7 required the treatment to be shortened or the needle replaced at another site, which cost the patient dialysis time; and 2 led to a visit to the emergency department for bleeding that could not be controlled at the center. None caused lasting harm. The seven shortened treatments connect this category to effectiveness as well as safety, since each one reduced a patient's dialysis dose for that session. Reporting harm levels alongside counts keeps the committee from treating a minor hematoma and an emergency visit as the same kind of event.
What the Counts Can and Cannot Say
Event reports measure what staff notice and choose to report, not everything that happens, so the counts are a floor rather than a total. The medication near-miss increase shows how a change in reporting behavior can move a count without any change in safety. The vascular access trend is more credible because it is in events that reached patients, which are harder to overlook, and because it is consistent with other data, the start-time audit and the patient comments. Reports also describe the last step in a chain rather than its causes; a system view of error asks why the conditions at shift change allow the same slip to recur (Reason, 2000). Small numbers also limit precision: a change of two or three events in a category like falls is within ordinary variation.
What Follows
Vascular access events on the second shift are the priority for the next stage: an analysis of their causes, using the categories people, process, equipment, supplies, environment and information. Falls, medication errors and bleeding from vascular access have long been named among the main safety problems in dialysis facilities (Kliger, 2006), and Gulfview's own data now point to the third as the one moving in the wrong direction.
References
Gu, X., Itoh, K., & Suzuki, S. (2014). An error taxonomy system for analysis of haemodialysis incidents. Journal of Renal Care, 40(4), 239-248. https://doi.org/10.1111/jorc.12081
Kliger, A. S. (2006). Patient safety in the dialysis facility. Blood Purification, 24(1), 19-21. https://doi.org/10.1159/000089431
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
Reading the HC 405 Unit 5 instructions
Unit 5 asks you to summarize incident trends for a health care organization. Expect to define what was counted, present a table by period and category, order categories by size, interpret the trends, convert counts to rates, consider harm, state what counts can and cannot show and identify the next priority. Students often ask whether rising reports mean more harm. Not always: better reporting can raise counts, so check whether the rise is in events that reached patients or in near misses. Split every cell that way. Use rates when volume changes. Order categories so the largest stands out. Remember that reports are a floor, not a total.
How the HC 405 Unit 5 example is put together
The summary opens with the period, the facility and how categories were assigned. The table shows six categories across four quarters, each cell split into reached and caught events. The ordered chart description ranks the categories and notes how far vascular access stands above the rest. The reading section shows access events climbing each quarter while medication near misses rose after a reporting campaign, a change in reporting rather than in harm. The rates section expresses events per 1,000 treatments and summarizes harm levels. The limits section explains that reports reflect what staff notice and choose to file. The final section makes second-shift access events the priority for a cause analysis and notes falls as the next concern.
Where the points sit in the HC 405 Unit 5 rubric
Herzing's rubric for an incident trend summary usually covers scope, the table, ordering, interpretation, rates and harm, limits and next steps. Separating events that reached patients from those caught in time gets the closest reading, since that split shows whether rising counts mean rising harm. Scope points reward a defined period and categories. Table criteria look for consistent cells across periods. Ordering credit goes to a ranked chart that highlights the largest category. Rate points reward denominators such as treatments. Limits should note reporting bias. Next steps should name one priority for analysis. Kliger's work on dialysis patient safety, Gu's error taxonomy for dialysis and Reason's model of human error support the summary.
HC 405 Unit 5 help: mistakes that cost points
Trend summaries in HC 405 Unit 5 frequently go wrong by treating every rise in reports as a rise in harm. Another frequent problem is mixing near misses with events that reached patients. Students often present counts without rates. Categories are listed in no order. A reporting campaign's effect is not considered. Harm levels are skipped. Limits of voluntary reporting are ignored. Next steps try to fix everything at once. Shift and time patterns are not checked, though a problem concentrated on one shift points to a different cause than one spread evenly across the day. Finally, split reached from caught, because graders reward a summary that points the next unit's analysis at the events actually hurting patients.
Get a HC 405 Unit 5 example written to your instructions
Send the Unit 5 instructions and the rubric from your HC 405 classroom, plus any event categories or figures your section supplied. We write a custom example with counts laid across equal periods, near misses on their own line, an ordered chart and a reading that questions the falling category, back in 24 to 48 hours. The first custom sample is free.
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HC 405 Unit 5 questions, answered
Can I use event data from my workplace?
Keep internal event files out of it, even where your instructions appear to permit them, because those records are ordinarily protected and do not belong in anything you submit. An invented series, made realistic and labeled as illustrative, carries the summary without difficulty. What must be real is the category scheme, the reasoning, and whatever published source you lean on for severity.
How many periods does a trend need?
More than two. Two points make a line and tell you nothing about whether the movement is ordinary, so aim for at least four or five equal stretches before calling anything a trend. If you have fewer, present the figures as a snapshot and say so, since a trend claimed on thin data is the easiest thing on the page to mark down.
Where should the categories come from?
Use a published taxonomy if your instructions name one, because borrowed categories come with definitions and a citation. Otherwise take the groupings a reporting system would realistically offer and define each one in a line, making sure they do not overlap. State the rule you applied to events that could belong in two categories, since that rule decides how readable the whole table is.
Where can I find a free HC 405 Unit 5 sample paper?
The full HC 405 Unit 5 incident trend summary is free on this page, a year of dialysis event reports by quarter and category with reached and caught events split. A summary for another facility can be written to order.
Do more incident reports mean more patient harm?
Not necessarily. Better reporting raises counts, so separate events that reached patients from near misses and use rates. This sample shows a rise in harm alongside a reporting effect.