Hospital Sentinel Event
NIGHTINGALE COMMUNITY
HOSPITAL.
RCA (ROOT CAUSE ANALYSIS)
FOR THE SENTINEL EVENT REPORT
HAPPENED ON MAY 14,
THURSDAY AT 9:00 AM.
1. SENTINEL EVENT DESCRIPTION.
The pre-op nurse told the mother that once Tina (The patient), a 3 years old child, went to the OR, her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour. The mother told the nurse that once Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number with instructions to contact her if Tina got out of surgery sooner than expected.
Tina’s mother returned to pick her approximately 2 ½ hours later and found that Tina was discharged 30 minutes earlier.
Tina’s mother was extremely distraught, security was called, and a “Code Pink” (hospital-wide child abduction alert) was activated. Local law enforcement was also contacted by hospital security. When the security officer interviewed the mother, she shared with him that she and Tina’s father were divorced and that she had full custody of Tina and her siblings.
Tina was located within 30 minutes of her mother’s arrival, by local law enforcement, in the care of her father. He had taken her to his home to await the arrival of the mother.
No charges were filed against the father.
2. PERSONNEL ROLES PRESENT DURING THE SENTINEL EVENT.
1. PREP-OP NURSE.
Prepared patient for surgery, brought the mother and daughter (Patient) to the prep-operative area, completed the prep-operative nursing assessment, changed the patient to a hospital gown, started the patient IV, administered the prep-op medications, documented in the administration medication record, asked the mother to sign the consent form for surgery, took the mother's name and
HOSPITAL.
RCA (ROOT CAUSE ANALYSIS)
FOR THE SENTINEL EVENT REPORT
HAPPENED ON MAY 14,
THURSDAY AT 9:00 AM.
1. SENTINEL EVENT DESCRIPTION.
The pre-op nurse told the mother that once Tina (The patient), a 3 years old child, went to the OR, her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour. The mother told the nurse that once Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number with instructions to contact her if Tina got out of surgery sooner than expected.
Tina’s mother returned to pick her approximately 2 ½ hours later and found that Tina was discharged 30 minutes earlier.
Tina’s mother was extremely distraught, security was called, and a “Code Pink” (hospital-wide child abduction alert) was activated. Local law enforcement was also contacted by hospital security. When the security officer interviewed the mother, she shared with him that she and Tina’s father were divorced and that she had full custody of Tina and her siblings.
Tina was located within 30 minutes of her mother’s arrival, by local law enforcement, in the care of her father. He had taken her to his home to await the arrival of the mother.
No charges were filed against the father.
2. PERSONNEL ROLES PRESENT DURING THE SENTINEL EVENT.
1. PREP-OP NURSE.
Prepared patient for surgery, brought the mother and daughter (Patient) to the prep-operative area, completed the prep-operative nursing assessment, changed the patient to a hospital gown, started the patient IV, administered the prep-op medications, documented in the administration medication record, asked the mother to sign the consent form for surgery, took the mother's name and