Aft2 Task 2
On Thursday September 14th at around 12:30 pm the hospital had a sentinel event which involved a missing child. The event details are as follows: Tina was scheduled for same day surgery and was brought to the hospital by her Mother. Her Mother was informed that the surgery would take approximately 45 minutes and that Tina would be in recovery at least 1 hour. Tina’s Mother informed the pre-op nurse that she had an errand to run involving Tina’s older sibling. Tina’s mother left the pre-op nurse her cell phone number with instructions to call her if Tina got out of surgery and was ready to go before she returned. Prior to Tina’s mother returning Tina’s father showed up to check on her, and finding that she was ready to go he took her to his house until the mother could pick her up. When Tina’s mother returned 2 ½ hours later she found Tina missing and the staff did not know that her father took her. The hospital activated a Code Pink and notified the local police department. When the hospital security interview the mother they learned the parents were divorced and that she had full custody of Tina and her other siblings. The local police found Tina at her father’s home within 30 minutes of Tina’s mother returning to the hospital. No charges were filed against the father.
There were eight main employees that interactive with Tina, her mother and father in the sentinel event. We will be looking at each of their roles in the order that Tina and her parents interacted with them:
Katie Jessup is the registrar that admitted Tina to the hospital. She asked the standard questions, made copies of the insurance information and recorded it all into the computer system for admission and billing. As she was trained she did not ask any questions that were not on the standard questionnaire form that all patients fill out.
Greta Doppke is the pre-op nurse who took Tina and her mother back to prepare for her surgery. Greta completed her nursing pre-op
There were eight main employees that interactive with Tina, her mother and father in the sentinel event. We will be looking at each of their roles in the order that Tina and her parents interacted with them:
Katie Jessup is the registrar that admitted Tina to the hospital. She asked the standard questions, made copies of the insurance information and recorded it all into the computer system for admission and billing. As she was trained she did not ask any questions that were not on the standard questionnaire form that all patients fill out.
Greta Doppke is the pre-op nurse who took Tina and her mother back to prepare for her surgery. Greta completed her nursing pre-op
References: Analysis of key components. In (2012). Nightingale Memorial Hospital Blakely , T Doppke, G. (2012, September 14). [Personal Interview]. Pre-O.P. Nurser Sentinel event interview Fry, R Jessup, K. (2012, September 14). Registrar [Personal Interview]. Sentinel event interview. Johnson, K. (2012, September 14). [Personal Interview]. Discharge Nurse Sentinel event interview. Liu-Dilaarno, A. (2012, September 14). C.N.O. [Personal Interview]. Sentinel event interview. Methods of quality improvement In (2005). Patient Safty - Quality Improvement Duke University Medical Department. Retrieved from http://patientsafetyed.duhs.duke.edu/module_a/methods/methods.html Munoz, C Peters, J. (2012, September 14). [Personal Interview]. Recovery Nurse Sentinel event interview. Sentinel event report. In (2012). Nightingale Memorial Hospital Sentinel event action plan – oig guidelines