Analysis Root Cause Analysis Sentinel Event
Root Cause Analysis: Review of a Sentinel Event
Western Governors University
Root Cause Analysis: Review of a Sentinel Event
Brief Description of the Event
A 13 year-old girl, Tina, was admitted for outpatient surgery on September 14. Tina was accompanied by her mother, who was informed by nursing personnel she would be in surgery approximately 45 minutes and then recovery for one hour. Tina’s mother informed nursing personnel that she would be leaving, but would provide her cell phone number to be notified if Tina was ready prior to the anticipated time. Tina’s surgery and recovery time did not last as long as expected and her mother was unaware she was ready to be dismissed from the hospital. In the mean time, Tina’s …show more content…
father came to see how she was doing. Prior to dismissal, hospital staff attempted to contact Tina’s mother via the telephone six times in 45 minutes per call logs, but were unable to make contact. Admitting paperwork and insurance information was reviewed with information showing the guarantor was Tina’s father. Nightingale Community Hospital followed the standard admitting and release procedures for their facility. Tina’s father did not seem nervous or suspicious and provided proper documentation of identity. Furthermore, Tina confirmed that he was her father and did not seem upset or surprised to see him. Tina was improperly discharged to her father against her mother’s wishes, due to the hospital personnel being unaware of the family situation.
Tina’s mother returned to the hospital after having been gone for two and one-half hours running errands. At this time, she learned that Tina had been discharged from the hospital with her father. Tina’s mother became extremely distraught and hospital security was contacted immediately. Tina’s mother informed hospital security that she was divorced from Tina’s father and she had retained full custody of Tina and her siblings. This type of information is not standard information required during the admitting process.
A child abduction alert or “Code Pink” was initiated. Hospital security notified local law enforcement of the child abduction and provided the father’s contact information and address. Tina’s father was contacted via telephone by local law enforcement and they proceeded to go to Tina’s father’s home to retrieve her. Tina was in local law enforcement custody within 30 minutes of her mother’s arrival to the hospital, after resting at her father’s home waiting for her mother to pick her up.
Personnel Involved
The following personnel participated in the sentinel event on September 14; registrar, pre-op nurse, OR nurse, recovery nurse, post-op nurse, surgeon, chief nursing officer, security and risk management. The areas affected during the sentinel event were registration, surgery, medical staff, security, and the hospital reputation. Interviews were conducted with personnel identified as being present and involved during this sentinel event.
The registrar verbalized she had initial contact with the child and her mother. She stated she obtained the required insurance information, made a copy of the card and entered this information into the electronic medical record. The registrar is initial point of contact for patients entering the hospital. The registrar will obtain patient information, have the patient or guardian sign appropriate HIPAA documents, provide the patients bill of rights and direct the patient to the correct area of the hospital or notify personnel to meet the patient and escort them to the appropriate area.
The pre-operative nurse has the responsibility of completing an assessment, verifying consents for surgical procedures are signed or obtaining the necessary consents, providing any educational needs, obtain contact information for the family in the event of emergency, start any pre-op IV’s, and administer pre-op medications. The pre-op nurse verbalized she had completed the required pre-op consents, assessments, and orders. She also obtained the mother’s contact information, but did not pass the information on instead placing the information in her notebook.
The OR nurse will transport the patient from pre-op holding to the operating room. The OR nurse will ensure the patient is educated and answer any questions/needs, provide documentation within the OR, complete counts of surgical instruments and sponges, transport patient to the recovery room and give report to the recovery room nurse. The interview with the OR nurse did not provide much detail, however, the OR nurse verbalized a better procedure for transferring care of patient needs to be implemented.
The recovery room nurse will help the patient transition from a sedated state to a more alert, conscious state. The recovery nurse will complete assessments, assess pain, provide medications as ordered, provide IV and oral fluids as ordered, update family members upon transfer of from recovery to post-op room. The recovery nurse interviewed verbalized the patient had no complications during the recovery experience. He attempted to contact the mother, but was unable to locate her. The patient became upset once she had begun to awaken, so he transferred the patient to the post-op area.
The post-op nurse will provide care to the patient post surgical procedures. The nurse will complete an assessment, provide IV and oral fluids as ordered, assess pain, administer medications as ordered, and monitor for output. Once the patient has become fully cognizant the nurse will provide education for home care, arrange for follow-up appointments, call prescriptions into the patient’s home pharmacy or provide written prescriptions and transport patient to awaiting ride home upon dismissal. The post-op nurse verbalized the patient care was transferred to her from recovery. The mother was not with the patient nor was she in the post-op room however a man presented who verbalized her was the patient’s father. The patient seemed to recognize the man and appeared to be comfortable with him. The patient was allowed to rest and once able to be dismissed the nurse discharged the patient with the father.
The surgeon will provide surgical care, provide dictation or documentation on patient history, assessment, procedural processes, verify consents, communicate with the patient’s family after the surgical procedure, provide written orders, and follow-up post-op. The surgeon verbalized he was aware of a custody arrangement and had outlined this in his office notes. The surgeon verbalized the hospital should have contacted his office for the records. The surgeon verbalized his displeasure with nursing personnel letting this incident happen and questioned if he should continue to allow his patients at NCH.
The chief nursing officer is ultimately responsible for all nursing practice within the organization. The chief nursing officer will follow-up and investigate patient concerns, provide appropriate resolutions, and provide communication between nursing personnel and physicians. The chief nursing officer verbalized she was not directly involved with the care of the patient, but was concerned how the event had been able to take place. She verbalized that there was a need for an improvement in communication.
The security officer provides a safe environment within an organization to protect patients, visitors, and employees. Security personnel will make rounds of the hospital, check secure areas, lock and unlock doors as appropriate, respond to requests for intervention, and respond to all alarms. The security officer verbalized there was a delay of notification regarding the child abduction. This then delayed the paging of the “Code Pink” and response time. The security officer was able to notify local law enforcement and secure the scene. The security officer then proceeded to conduct interviews with personnel identified as those involved with the sentinel event.
Personnel Issues
The Nightingale personnel involved at some stage in the sentinel event are as follows, the initial contact came when the admitting personnel obtained the patient demographics and insurance information. No custody information was obtained, but is not required per hospital policy. The patient, accompanied by her mother, was then taken to the pre-operative area by nursing personnel.
The pre-operative nurse helped Tina into a hospital gown, an IV was started, medications were given and assessment was completed. Next, the surgical nurse took the patient to the operating room and was present for the procedure. The surgeon performed the procedure, but did not have all the pertinent information from his office concerning the patient sent to the hospital.
Upon completion of surgery, care was then transferred to the post-anesthesia care nurse until Tina could be transferred to the outpatient care area for dismissal. The post-anesthesia care nurse paged for Tina’s mother, but was not able to contact her.
Finally, care was transferred to the outpatient care nurse who would be caring for Tina through dismissal. The outpatient care nurse dismissed Tina into her father’s care when she was finally able to leave the hospital. The outpatient care nurse did not attempt to contact Tina’s mother.
Security personnel were involved upon the return of the mother and her emotional dishevel. Security personnel responded to the child abduction signal and contacted local law enforcement.
The hospital was not notified of any custody issues involving Tina and her family. The surgeon was aware, but his office failed to provide the pertinent information to Nightingale Community Hospital. The NCH admitting personnel were unaware of any custody issues and did not ask for nor collect any information regarding custody. This type of information is not routinely inquired about and is not part of standard procedures at NCH.
Tina’s mother verbalized to the pre-operative nurse that she would like to be contacted upon completion of her daughter’s procedure. She provided a contact number to be reached. The fact the mother wanted notified, however, was not passed on to each nurse during the transfer of care. This meant the mother was not notified. Thus, she was not aware her daughter’s procedure had been completed. Hospital personnel admit and agree that no protocol exists for transferring patient care from one area to another.
Improve Interactions
A protocol should be implemented that improves communication and interactions among personnel. The pertinent information must be known by all caring for the patient and be given to each person providing care. Preventing similar events requires effective interactions between personnel must take place. The development of a “standard” transfer report must be initiated and adhered to by personnel. This will ensure all pertinent information will be passed on from one healthcare provider to another.
One protocol to consider when dismissing a minor from NCH should be to confirm with the accompanying parent or guardian who the minor will be dismissed from the hospital with. Also, a matching ID bracelet should be given to that individual and placed on the patient. The hospital personnel should be required to compare these ID bracelets prior to release and if they do not match, then release should not be completed.
Quality Improvement Method
Quality improvement is the process of reviewing previous and current policy and procedures then looking forward to improve them.
Simply put, quality improvement is making things better. Quality improvement concentrates on procedural issues due to deficiencies and errors that are often the result failures in the organization. The FADE method is utilized to focus, analyze, develop, execute, and evaluate patient safety and quality improvement. Nightingale Community Hospital should implement this method for analysis, implementation and reviewing procedures within the organization and provide guidance in the root cause …show more content…
analysis. The FADE model is complex and provides detailed instruction and direction. It is easy to use and implement within an organization. The model is able to provide a way to look at a situation from different angles then work to improve it.
Focus is the initial step in the FADE model. To focus, one needs to identify and verify the problem. NCH identified an issue with preventing child abduction. The event occurred at dismissal, but could happen within any hospital area.
Analysis of the event is the next step. This is when the organization should look at what went wrong. What is important information to this event and what is not? The investigation should begin by collecting information on how this event occurred, is there a pattern that contributed to this event, and what things could influence this event from reoccurring. The more information available for analysis will help lead to a better understanding to fix the problem.
Develop a method to formulate a plan of action is the third step. The organization must develop a method that will help solve the problem. The organization should form a committee that comprises all areas of the facility to obtain multiple views. The rationale for multiple views is to help develop a solution that will help all areas of the organization and not be self-limited. A solution or method to solve the problem should be developed along with the timeframe to implement the solution. Personnel training and education must take place prior to the implementation so all staff utilize the new solution.
Once personnel training and education has been completed then the solution or method can be executed. The personnel should now be utilizing the new solution. Monitoring will need to be performed to evaluate the progress of the method, how the solution has impacted areas, do the employees have the proper equipment, was the method implemented in a timely manner and was the new method adhered to. The evaluation of the newly implemented method will need time to be fully monitored and determined to be successful or not. If the evaluation indicates the new solution has been successful, then continued monitoring will be needed however if it was unsuccessful then the FADE method begins again.
Quality improvement is vital within a hospital organization. Quality improvement provides for patient safety and continued improvement of patient care. The FADE method can benefit NCH root cause analysis through focusing, analyzing, developing, executing and evaluating the successes and failures of methods improved and implemented. The Joint Commission (2013) requires all sentinel events are to be reported and organizations are required to cultivate solutions to prevent the event from reoccurring. The FADE method will ensure NCH will be in compliance with The Joint Commission standards.
Risk Management Program
Hospitals carry inherent risks, thus risk management departments are essential (McClinton, 2011). The ideal goal is to prevent all risks that accompany a hospital. However, this is an unrealistic goal. All patients are at risk upon entering the hospital. They risk exposure to communicable disease, injury, or even financial loss.
Risk management programs examine what potential situations, behaviors, or procedures may harm a patient or personnel (Johnson, 2010). Situations will be focused on, analyzed, a corrective plan will be developed then executed and finally the plan will be evaluated for success or failure.
Corrective Action Plan—FADE Method
Focus: A child abduction had taken place 25 minutes prior to security being notified. Analyze: What caused the delay in security notification? The discharge nurse was unaware of a custody issue between the parents of the child and the child was dismissed to the non-custodial parent. The mother was not on the unit at dismissal, but returned and found the child gone. The mother then notified personnel that her child was abducted. What could have prevented this event? The organization personnel being aware of the home environment and living situation. Develop: A standard procedure that states no delay should take place in notifying security when child abduction is actual or potential in nature. This policy should be consistent throughout the organization. Personal safety sensors attached to an ID band should be utilized on all minors, unless a parent or guardian has signed a refusal. Execute: This policy is to become effective on 11/1/2013. Security personnel are responsible for ordering sensors to be attached to ID bands. Admission staff are responsible for placement of the sensors on all minor ID bands during completion of the admission process. Staff providing direct patient care are responsible for maintaining the integrity of the sensors and ID bands. If integrity is suspect, then security personnel should be contacted for replacement sensors, ID bands, and to verify parent or guardian information. Security personnel will hold child abduction drills on all shifts every 6 months and as needed. Evaluation: Quality improvement, risk management, and security personnel are responsible for evaluating the implemented sensor plan for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Focus: Custody information was not obtained during the admission process. No proof of identity was obtained. Analyze: Why was the hospital unaware of the custody information? No standard protocol existed regarding a minor patient’s home address, parent/parents/guardian information, along with contact information and an emergency contact should the responsible party not be contacted existed at the time the event took place. How could this event be prevented from reoccurring? A home environment assessment including with whom the patient resides should be completed with admission procedures. Develop: A standard procedure of obtaining information regarding a minor’s living arrangements will be obtained during the admission process. The electronic medical record will be updated to reflect questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will be triggered and required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the information on the electronic medical record. Admission staff is responsible for entering the appropriate data and answering the questions when triggered. Security staff is responsible for ordering and providing the sensors to attach to the ID bracelets. Direct care contact staff is responsible for monitoring the integrity of the sensors and ID bracelets. If integrity is suspect, security will be contacted to replace the sensor and ID bracelet. Verification of the parent or guardian will be completed by security when replacing a sensor and ID bracelet. Nursing personnel is responsible for verifying the minor patient is being discharged to home with the appropriate individual by comparing the EMR and government issued ID prior to leaving the unit and documenting the verification in the EMR. Evaluation: Quality improvement, risk management, security personnel, IT personnel, and chief nursing officer are responsible for evaluating the implemented sensor plan, EMR birthdate trigger for follow-up questions, and verification of responsible party for discharge and documentation of verification process for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Focus: Hospital personnel were unable to contact the mother.
The patient was released to her father when the mother was unable to be located. Analyze: Why was the mother not contacted? The nurse attempted to page the mother, but she could not be located. No other attempt to locate the mother was made. Why was the patient discharged to home with the father before the mother could be located? Housekeeping was on the unit waiting to clean the room for the next admission. How could this event have been prevented? Develop: The admission process will begin with identification of patient and parent or guardian, EMR follow-up questions will be triggered by the patient birthdate. The questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Housekeeping will not be notified of pending admissions until the room is empty and the patient has been discharged. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the
information on the electronic medical record. Admission staff is responsible for entering the appropriate data and answering the questions when triggered. Security staff is responsible for ordering and providing the sensors to attach to the ID bracelets. Direct care contact staff is responsible for monitoring the integrity of the sensors and ID bracelets. If integrity is suspect, security will be contacted to replace the sensor and ID bracelet. Verification of the parent or guardian will be completed by security when replacing a sensor and ID bracelet. Nursing personnel is responsible for verifying the minor patient is being discharged to home with the appropriate individual by comparing the EMR and government issued ID prior to leaving the unit and documenting the verification in the EMR. Housekeeping will be notified of the need to clean a room for an admission only after the current patient occupying the room has been discharged from the facility. Evaluation: Quality improvement, risk management, security personnel, IT personnel, and chief nursing officer are responsible for evaluating the implemented sensor plan, EMR birthdate trigger for follow-up questions, and verification of responsible party for discharge and documentation of verification process for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. Housekeeping personnel will keep a log for notification of room dismissals. If a room is still found to be occupied, then housekeeping personnel will notify the chief nursing officer. The chief nursing officer will be responsible for educating nursing staff on verification during dismissal and dismissal procedures. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Focus: The only information the nurses received was procedural only. No relevant background information was received. The post-anesthesia nurse was made aware the mother accompanied the patient, but was not given the information she would like to be contacted when the patient was transferred to the outpatient area. The nurse paged the mother, but did not follow-up when she was not located. Analysis: The mother provided a contact number, but it was not given to other appropriate nursing personnel. How can staff ensure this type of information is available to all staff? The EMR should have available all contact information, who accompanied the patient, who will the patient be dismissed to home with. Develop: The admission process will begin with identification of patient and parent or guardian, EMR follow-up questions will be triggered by the patient birthdate. The questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the information on the electronic medical record. Admission staff is responsible for entering the appropriate data and answering the questions when triggered. Security staff is responsible for ordering and providing the sensors to attach to the ID bracelets. Direct care contact staff is responsible for monitoring the integrity of the sensors and ID bracelets. If integrity is suspect, security will be contacted to replace the sensor and ID bracelet. Verification of the parent or guardian will be completed by security when replacing a sensor and ID bracelet. Nursing personnel is responsible for verifying the minor patient is being discharged to home with the appropriate individual by comparing the EMR and government issued ID prior to leaving the unit and documenting the verification in the EMR. Evaluation: Quality improvement, risk management, security personnel, IT personnel, and chief nursing officer are responsible for evaluating the implemented sensor plan, EMR birthdate trigger for follow-up questions, and verification of responsible party for discharge and documentation of verification process for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. Housekeeping personnel will keep a log for notification of room dismissals. If a room is still found to be occupied, then housekeeping personnel will notify the chief nursing officer. The chief nursing officer will be responsible for educating nursing staff on verification during dismissal and dismissal procedures. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Quality patient care is contingent upon multidisciplinary teams operating together to bring about change. These teams require coordination of activities to be effective in their individual departments. Overall, if teamwork occurs the patient and organization benefits.
Resources
Resources are abundant. The Internet alone provides a vast array of information to help a healthcare organization get started. Platforms are available to enrich risk management programs that help focus on business and reduce risks in practices.
Formulating goals and setting timelines for compliance are part of Six Sigma programs and programs like it. Six Sigma programs help organizations define and identify specific goals. These goals are then measured and reviewed to move forward with specific goals. The effectiveness of Six Sigma programs is then documented and the procedures of the organization are defined. This may include patient care, medical procedures, and flow of information.
Patient safety is, without a doubt, the most important aspect within a hospital organization. To be effective, all departments must work together, however risk management and quality improvement must integrate identities to better recognize and address potential complications. This will help make operations more efficient by reducing error and ligation rates.
References
Johnson, T. (2010). Definition of health care risk management. Retrieved from http://www.ehow.com/about_638520_definition-health-care-risk-management.html McClinton, R. (2011). Why are risk management teams necessary for hospitals?
Retrieved from http://www.ehow.com/about_5497551_risk-management-teams-necessary-hospitals.html
Patient safety—Quality improvement. FADE method. Retrieved from
http://patientsafetyed.duhs.duke.edu/module_a/methods/fade.html
Western Governors University
Root Cause Analysis: Review of a Sentinel Event
Brief Description of the Event
A 13 year-old girl, Tina, was admitted for outpatient surgery on September 14. Tina was accompanied by her mother, who was informed by nursing personnel she would be in surgery approximately 45 minutes and then recovery for one hour. Tina’s mother informed nursing personnel that she would be leaving, but would provide her cell phone number to be notified if Tina was ready prior to the anticipated time. Tina’s surgery and recovery time did not last as long as expected and her mother was unaware she was ready to be dismissed from the hospital. In the mean time, Tina’s …show more content…
father came to see how she was doing. Prior to dismissal, hospital staff attempted to contact Tina’s mother via the telephone six times in 45 minutes per call logs, but were unable to make contact. Admitting paperwork and insurance information was reviewed with information showing the guarantor was Tina’s father. Nightingale Community Hospital followed the standard admitting and release procedures for their facility. Tina’s father did not seem nervous or suspicious and provided proper documentation of identity. Furthermore, Tina confirmed that he was her father and did not seem upset or surprised to see him. Tina was improperly discharged to her father against her mother’s wishes, due to the hospital personnel being unaware of the family situation.
Tina’s mother returned to the hospital after having been gone for two and one-half hours running errands. At this time, she learned that Tina had been discharged from the hospital with her father. Tina’s mother became extremely distraught and hospital security was contacted immediately. Tina’s mother informed hospital security that she was divorced from Tina’s father and she had retained full custody of Tina and her siblings. This type of information is not standard information required during the admitting process.
A child abduction alert or “Code Pink” was initiated. Hospital security notified local law enforcement of the child abduction and provided the father’s contact information and address. Tina’s father was contacted via telephone by local law enforcement and they proceeded to go to Tina’s father’s home to retrieve her. Tina was in local law enforcement custody within 30 minutes of her mother’s arrival to the hospital, after resting at her father’s home waiting for her mother to pick her up.
Personnel Involved
The following personnel participated in the sentinel event on September 14; registrar, pre-op nurse, OR nurse, recovery nurse, post-op nurse, surgeon, chief nursing officer, security and risk management. The areas affected during the sentinel event were registration, surgery, medical staff, security, and the hospital reputation. Interviews were conducted with personnel identified as being present and involved during this sentinel event.
The registrar verbalized she had initial contact with the child and her mother. She stated she obtained the required insurance information, made a copy of the card and entered this information into the electronic medical record. The registrar is initial point of contact for patients entering the hospital. The registrar will obtain patient information, have the patient or guardian sign appropriate HIPAA documents, provide the patients bill of rights and direct the patient to the correct area of the hospital or notify personnel to meet the patient and escort them to the appropriate area.
The pre-operative nurse has the responsibility of completing an assessment, verifying consents for surgical procedures are signed or obtaining the necessary consents, providing any educational needs, obtain contact information for the family in the event of emergency, start any pre-op IV’s, and administer pre-op medications. The pre-op nurse verbalized she had completed the required pre-op consents, assessments, and orders. She also obtained the mother’s contact information, but did not pass the information on instead placing the information in her notebook.
The OR nurse will transport the patient from pre-op holding to the operating room. The OR nurse will ensure the patient is educated and answer any questions/needs, provide documentation within the OR, complete counts of surgical instruments and sponges, transport patient to the recovery room and give report to the recovery room nurse. The interview with the OR nurse did not provide much detail, however, the OR nurse verbalized a better procedure for transferring care of patient needs to be implemented.
The recovery room nurse will help the patient transition from a sedated state to a more alert, conscious state. The recovery nurse will complete assessments, assess pain, provide medications as ordered, provide IV and oral fluids as ordered, update family members upon transfer of from recovery to post-op room. The recovery nurse interviewed verbalized the patient had no complications during the recovery experience. He attempted to contact the mother, but was unable to locate her. The patient became upset once she had begun to awaken, so he transferred the patient to the post-op area.
The post-op nurse will provide care to the patient post surgical procedures. The nurse will complete an assessment, provide IV and oral fluids as ordered, assess pain, administer medications as ordered, and monitor for output. Once the patient has become fully cognizant the nurse will provide education for home care, arrange for follow-up appointments, call prescriptions into the patient’s home pharmacy or provide written prescriptions and transport patient to awaiting ride home upon dismissal. The post-op nurse verbalized the patient care was transferred to her from recovery. The mother was not with the patient nor was she in the post-op room however a man presented who verbalized her was the patient’s father. The patient seemed to recognize the man and appeared to be comfortable with him. The patient was allowed to rest and once able to be dismissed the nurse discharged the patient with the father.
The surgeon will provide surgical care, provide dictation or documentation on patient history, assessment, procedural processes, verify consents, communicate with the patient’s family after the surgical procedure, provide written orders, and follow-up post-op. The surgeon verbalized he was aware of a custody arrangement and had outlined this in his office notes. The surgeon verbalized the hospital should have contacted his office for the records. The surgeon verbalized his displeasure with nursing personnel letting this incident happen and questioned if he should continue to allow his patients at NCH.
The chief nursing officer is ultimately responsible for all nursing practice within the organization. The chief nursing officer will follow-up and investigate patient concerns, provide appropriate resolutions, and provide communication between nursing personnel and physicians. The chief nursing officer verbalized she was not directly involved with the care of the patient, but was concerned how the event had been able to take place. She verbalized that there was a need for an improvement in communication.
The security officer provides a safe environment within an organization to protect patients, visitors, and employees. Security personnel will make rounds of the hospital, check secure areas, lock and unlock doors as appropriate, respond to requests for intervention, and respond to all alarms. The security officer verbalized there was a delay of notification regarding the child abduction. This then delayed the paging of the “Code Pink” and response time. The security officer was able to notify local law enforcement and secure the scene. The security officer then proceeded to conduct interviews with personnel identified as those involved with the sentinel event.
Personnel Issues
The Nightingale personnel involved at some stage in the sentinel event are as follows, the initial contact came when the admitting personnel obtained the patient demographics and insurance information. No custody information was obtained, but is not required per hospital policy. The patient, accompanied by her mother, was then taken to the pre-operative area by nursing personnel.
The pre-operative nurse helped Tina into a hospital gown, an IV was started, medications were given and assessment was completed. Next, the surgical nurse took the patient to the operating room and was present for the procedure. The surgeon performed the procedure, but did not have all the pertinent information from his office concerning the patient sent to the hospital.
Upon completion of surgery, care was then transferred to the post-anesthesia care nurse until Tina could be transferred to the outpatient care area for dismissal. The post-anesthesia care nurse paged for Tina’s mother, but was not able to contact her.
Finally, care was transferred to the outpatient care nurse who would be caring for Tina through dismissal. The outpatient care nurse dismissed Tina into her father’s care when she was finally able to leave the hospital. The outpatient care nurse did not attempt to contact Tina’s mother.
Security personnel were involved upon the return of the mother and her emotional dishevel. Security personnel responded to the child abduction signal and contacted local law enforcement.
The hospital was not notified of any custody issues involving Tina and her family. The surgeon was aware, but his office failed to provide the pertinent information to Nightingale Community Hospital. The NCH admitting personnel were unaware of any custody issues and did not ask for nor collect any information regarding custody. This type of information is not routinely inquired about and is not part of standard procedures at NCH.
Tina’s mother verbalized to the pre-operative nurse that she would like to be contacted upon completion of her daughter’s procedure. She provided a contact number to be reached. The fact the mother wanted notified, however, was not passed on to each nurse during the transfer of care. This meant the mother was not notified. Thus, she was not aware her daughter’s procedure had been completed. Hospital personnel admit and agree that no protocol exists for transferring patient care from one area to another.
Improve Interactions
A protocol should be implemented that improves communication and interactions among personnel. The pertinent information must be known by all caring for the patient and be given to each person providing care. Preventing similar events requires effective interactions between personnel must take place. The development of a “standard” transfer report must be initiated and adhered to by personnel. This will ensure all pertinent information will be passed on from one healthcare provider to another.
One protocol to consider when dismissing a minor from NCH should be to confirm with the accompanying parent or guardian who the minor will be dismissed from the hospital with. Also, a matching ID bracelet should be given to that individual and placed on the patient. The hospital personnel should be required to compare these ID bracelets prior to release and if they do not match, then release should not be completed.
Quality Improvement Method
Quality improvement is the process of reviewing previous and current policy and procedures then looking forward to improve them.
Simply put, quality improvement is making things better. Quality improvement concentrates on procedural issues due to deficiencies and errors that are often the result failures in the organization. The FADE method is utilized to focus, analyze, develop, execute, and evaluate patient safety and quality improvement. Nightingale Community Hospital should implement this method for analysis, implementation and reviewing procedures within the organization and provide guidance in the root cause …show more content…
analysis. The FADE model is complex and provides detailed instruction and direction. It is easy to use and implement within an organization. The model is able to provide a way to look at a situation from different angles then work to improve it.
Focus is the initial step in the FADE model. To focus, one needs to identify and verify the problem. NCH identified an issue with preventing child abduction. The event occurred at dismissal, but could happen within any hospital area.
Analysis of the event is the next step. This is when the organization should look at what went wrong. What is important information to this event and what is not? The investigation should begin by collecting information on how this event occurred, is there a pattern that contributed to this event, and what things could influence this event from reoccurring. The more information available for analysis will help lead to a better understanding to fix the problem.
Develop a method to formulate a plan of action is the third step. The organization must develop a method that will help solve the problem. The organization should form a committee that comprises all areas of the facility to obtain multiple views. The rationale for multiple views is to help develop a solution that will help all areas of the organization and not be self-limited. A solution or method to solve the problem should be developed along with the timeframe to implement the solution. Personnel training and education must take place prior to the implementation so all staff utilize the new solution.
Once personnel training and education has been completed then the solution or method can be executed. The personnel should now be utilizing the new solution. Monitoring will need to be performed to evaluate the progress of the method, how the solution has impacted areas, do the employees have the proper equipment, was the method implemented in a timely manner and was the new method adhered to. The evaluation of the newly implemented method will need time to be fully monitored and determined to be successful or not. If the evaluation indicates the new solution has been successful, then continued monitoring will be needed however if it was unsuccessful then the FADE method begins again.
Quality improvement is vital within a hospital organization. Quality improvement provides for patient safety and continued improvement of patient care. The FADE method can benefit NCH root cause analysis through focusing, analyzing, developing, executing and evaluating the successes and failures of methods improved and implemented. The Joint Commission (2013) requires all sentinel events are to be reported and organizations are required to cultivate solutions to prevent the event from reoccurring. The FADE method will ensure NCH will be in compliance with The Joint Commission standards.
Risk Management Program
Hospitals carry inherent risks, thus risk management departments are essential (McClinton, 2011). The ideal goal is to prevent all risks that accompany a hospital. However, this is an unrealistic goal. All patients are at risk upon entering the hospital. They risk exposure to communicable disease, injury, or even financial loss.
Risk management programs examine what potential situations, behaviors, or procedures may harm a patient or personnel (Johnson, 2010). Situations will be focused on, analyzed, a corrective plan will be developed then executed and finally the plan will be evaluated for success or failure.
Corrective Action Plan—FADE Method
Focus: A child abduction had taken place 25 minutes prior to security being notified. Analyze: What caused the delay in security notification? The discharge nurse was unaware of a custody issue between the parents of the child and the child was dismissed to the non-custodial parent. The mother was not on the unit at dismissal, but returned and found the child gone. The mother then notified personnel that her child was abducted. What could have prevented this event? The organization personnel being aware of the home environment and living situation. Develop: A standard procedure that states no delay should take place in notifying security when child abduction is actual or potential in nature. This policy should be consistent throughout the organization. Personal safety sensors attached to an ID band should be utilized on all minors, unless a parent or guardian has signed a refusal. Execute: This policy is to become effective on 11/1/2013. Security personnel are responsible for ordering sensors to be attached to ID bands. Admission staff are responsible for placement of the sensors on all minor ID bands during completion of the admission process. Staff providing direct patient care are responsible for maintaining the integrity of the sensors and ID bands. If integrity is suspect, then security personnel should be contacted for replacement sensors, ID bands, and to verify parent or guardian information. Security personnel will hold child abduction drills on all shifts every 6 months and as needed. Evaluation: Quality improvement, risk management, and security personnel are responsible for evaluating the implemented sensor plan for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Focus: Custody information was not obtained during the admission process. No proof of identity was obtained. Analyze: Why was the hospital unaware of the custody information? No standard protocol existed regarding a minor patient’s home address, parent/parents/guardian information, along with contact information and an emergency contact should the responsible party not be contacted existed at the time the event took place. How could this event be prevented from reoccurring? A home environment assessment including with whom the patient resides should be completed with admission procedures. Develop: A standard procedure of obtaining information regarding a minor’s living arrangements will be obtained during the admission process. The electronic medical record will be updated to reflect questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will be triggered and required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the information on the electronic medical record. Admission staff is responsible for entering the appropriate data and answering the questions when triggered. Security staff is responsible for ordering and providing the sensors to attach to the ID bracelets. Direct care contact staff is responsible for monitoring the integrity of the sensors and ID bracelets. If integrity is suspect, security will be contacted to replace the sensor and ID bracelet. Verification of the parent or guardian will be completed by security when replacing a sensor and ID bracelet. Nursing personnel is responsible for verifying the minor patient is being discharged to home with the appropriate individual by comparing the EMR and government issued ID prior to leaving the unit and documenting the verification in the EMR. Evaluation: Quality improvement, risk management, security personnel, IT personnel, and chief nursing officer are responsible for evaluating the implemented sensor plan, EMR birthdate trigger for follow-up questions, and verification of responsible party for discharge and documentation of verification process for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Focus: Hospital personnel were unable to contact the mother.
The patient was released to her father when the mother was unable to be located. Analyze: Why was the mother not contacted? The nurse attempted to page the mother, but she could not be located. No other attempt to locate the mother was made. Why was the patient discharged to home with the father before the mother could be located? Housekeeping was on the unit waiting to clean the room for the next admission. How could this event have been prevented? Develop: The admission process will begin with identification of patient and parent or guardian, EMR follow-up questions will be triggered by the patient birthdate. The questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Housekeeping will not be notified of pending admissions until the room is empty and the patient has been discharged. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the
information on the electronic medical record. Admission staff is responsible for entering the appropriate data and answering the questions when triggered. Security staff is responsible for ordering and providing the sensors to attach to the ID bracelets. Direct care contact staff is responsible for monitoring the integrity of the sensors and ID bracelets. If integrity is suspect, security will be contacted to replace the sensor and ID bracelet. Verification of the parent or guardian will be completed by security when replacing a sensor and ID bracelet. Nursing personnel is responsible for verifying the minor patient is being discharged to home with the appropriate individual by comparing the EMR and government issued ID prior to leaving the unit and documenting the verification in the EMR. Housekeeping will be notified of the need to clean a room for an admission only after the current patient occupying the room has been discharged from the facility. Evaluation: Quality improvement, risk management, security personnel, IT personnel, and chief nursing officer are responsible for evaluating the implemented sensor plan, EMR birthdate trigger for follow-up questions, and verification of responsible party for discharge and documentation of verification process for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. Housekeeping personnel will keep a log for notification of room dismissals. If a room is still found to be occupied, then housekeeping personnel will notify the chief nursing officer. The chief nursing officer will be responsible for educating nursing staff on verification during dismissal and dismissal procedures. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Focus: The only information the nurses received was procedural only. No relevant background information was received. The post-anesthesia nurse was made aware the mother accompanied the patient, but was not given the information she would like to be contacted when the patient was transferred to the outpatient area. The nurse paged the mother, but did not follow-up when she was not located. Analysis: The mother provided a contact number, but it was not given to other appropriate nursing personnel. How can staff ensure this type of information is available to all staff? The EMR should have available all contact information, who accompanied the patient, who will the patient be dismissed to home with. Develop: The admission process will begin with identification of patient and parent or guardian, EMR follow-up questions will be triggered by the patient birthdate. The questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the information on the electronic medical record. Admission staff is responsible for entering the appropriate data and answering the questions when triggered. Security staff is responsible for ordering and providing the sensors to attach to the ID bracelets. Direct care contact staff is responsible for monitoring the integrity of the sensors and ID bracelets. If integrity is suspect, security will be contacted to replace the sensor and ID bracelet. Verification of the parent or guardian will be completed by security when replacing a sensor and ID bracelet. Nursing personnel is responsible for verifying the minor patient is being discharged to home with the appropriate individual by comparing the EMR and government issued ID prior to leaving the unit and documenting the verification in the EMR. Evaluation: Quality improvement, risk management, security personnel, IT personnel, and chief nursing officer are responsible for evaluating the implemented sensor plan, EMR birthdate trigger for follow-up questions, and verification of responsible party for discharge and documentation of verification process for compliance and effectiveness at 1 month, 3 months, 6 months, and 12 months. Housekeeping personnel will keep a log for notification of room dismissals. If a room is still found to be occupied, then housekeeping personnel will notify the chief nursing officer. The chief nursing officer will be responsible for educating nursing staff on verification during dismissal and dismissal procedures. If effectiveness is not shown at 3 months, then a committee will be convened and the plan will be analyzed for strengths and weaknesses.
Quality patient care is contingent upon multidisciplinary teams operating together to bring about change. These teams require coordination of activities to be effective in their individual departments. Overall, if teamwork occurs the patient and organization benefits.
Resources
Resources are abundant. The Internet alone provides a vast array of information to help a healthcare organization get started. Platforms are available to enrich risk management programs that help focus on business and reduce risks in practices.
Formulating goals and setting timelines for compliance are part of Six Sigma programs and programs like it. Six Sigma programs help organizations define and identify specific goals. These goals are then measured and reviewed to move forward with specific goals. The effectiveness of Six Sigma programs is then documented and the procedures of the organization are defined. This may include patient care, medical procedures, and flow of information.
Patient safety is, without a doubt, the most important aspect within a hospital organization. To be effective, all departments must work together, however risk management and quality improvement must integrate identities to better recognize and address potential complications. This will help make operations more efficient by reducing error and ligation rates.
References
Johnson, T. (2010). Definition of health care risk management. Retrieved from http://www.ehow.com/about_638520_definition-health-care-risk-management.html McClinton, R. (2011). Why are risk management teams necessary for hospitals?
Retrieved from http://www.ehow.com/about_5497551_risk-management-teams-necessary-hospitals.html
Patient safety—Quality improvement. FADE method. Retrieved from
http://patientsafetyed.duhs.duke.edu/module_a/methods/fade.html