Nightingale Community Hospital: Sentinel Event
Western Governors University
Joint Commission Compliance Audit
Task 2
AFT2 Accreditation Audit
By Cricket Besse 055895
Nightingale Community Hospital
Sentinel Event
Registrar, registered child (3 year old patient), obtained insurance card and entered demographics. She was then taken to pre-op where the nurse told mother that once in the OR the surgery would take about 45 minutes and then she would go to recovery. The mother informed the pre-op nurse that once her daughter went into the O.R. 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 phone number with instructions to contact her if her daughter got out of surgery sooner than expected. The Pre-op nurse wrote her number down on her note pad that she carries around in her pocket. The daughter was taken into surgery by the O.R. nurse nothing was mentioned about the mothers’ phone number or contact instructions to the O.R. nurse. After surgery the daughter was taken to recovery where the recovery nurse took care of the patient until she was ready to go to the discharge ambulatory care. The recovery nurse paged the patients’ mother when she was coming out of anesthesia, but could not locate her. The recovery nurse kept her until ready to go to the ambulatory care for discharge. Security had called and said the father was at the main reception to come visit the daughter. The discharge nurse also tried to page mother, who still was not available. The patient was crying and wanted to go home. The discharge nurse let the father back to see the daughter. After 30 minutes had passed and mother was still not present, the father offered to take the patient, home with him. Since the patient called him daddy and was excited to see him, discharge nurse thought it was ok to send her home with her father. The discharge nurse had him sign all pertinent paperwork
Joint Commission Compliance Audit
Task 2
AFT2 Accreditation Audit
By Cricket Besse 055895
Nightingale Community Hospital
Sentinel Event
Registrar, registered child (3 year old patient), obtained insurance card and entered demographics. She was then taken to pre-op where the nurse told mother that once in the OR the surgery would take about 45 minutes and then she would go to recovery. The mother informed the pre-op nurse that once her daughter went into the O.R. 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 phone number with instructions to contact her if her daughter got out of surgery sooner than expected. The Pre-op nurse wrote her number down on her note pad that she carries around in her pocket. The daughter was taken into surgery by the O.R. nurse nothing was mentioned about the mothers’ phone number or contact instructions to the O.R. nurse. After surgery the daughter was taken to recovery where the recovery nurse took care of the patient until she was ready to go to the discharge ambulatory care. The recovery nurse paged the patients’ mother when she was coming out of anesthesia, but could not locate her. The recovery nurse kept her until ready to go to the ambulatory care for discharge. Security had called and said the father was at the main reception to come visit the daughter. The discharge nurse also tried to page mother, who still was not available. The patient was crying and wanted to go home. The discharge nurse let the father back to see the daughter. After 30 minutes had passed and mother was still not present, the father offered to take the patient, home with him. Since the patient called him daddy and was excited to see him, discharge nurse thought it was ok to send her home with her father. The discharge nurse had him sign all pertinent paperwork
References: JCI Accreditation Standards for Hospitals, 4th edition (e-book); July 2010 Philip Stahel; Patient Safety Surgery Journal, 2009, 3:14 Langley G.L., Nolan K M, Norman C L, Provost LP The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition) San Francisco: Jossey-Bass Publishing; 2009