Sentinel Event
A1. Sentinel Event
Review of the medical record for the specified patient (SP) was completed 09/16/12. The medical record revealed that the SP was a minor child with a diagnosis of history of frequent and recurrent tonsillitis and was scheduled to have the tonsils and adenoids removed 09/14/12 at 10:30 AM as an outpatient procedure. Review of the medical record for the day of 09/14/12 revealed that the SP was admitted to the pre-admission testing area at 9:00 AM. At 10:00 AM the SP was in the pre-operative area with the peripheral intravenous line in place and the pre-operative medications were being administered. At 10:30 AM the SP was in the operating room (OR) and the procedure was performed as scheduled. At 11:15 AM, the SP was moved from the OR to the post anesthesia care unit (PACU). At 12:15 PM, the SP was successfully recovered from the procedure and both the surgeon and the anesthesiologist cleared the SP to go home. The medical record revealed a nurse’s note by the pre-operative nurse on 09/14/12 at 10:30 AM that documented a conversation between the pre-operative nurse and the SP’s mother where the mother stated she was leaving to run an errand involving an older sibling and left a cellular telephone number. The only documented instruction from the mother was for the nurse to call if the SP got out of surgery sooner than expected. In an interview with the PACU nurse conducted on 09/15/12 at 10:00 AM, the PACU nurse stated that on 09/14/12 at approximately 12:30 PM, the patient was released for home to her father, who was identified by his driver’s license; the PACU nurse stated that she provided written instructions for the patient’s post-operative care and follow up appointment to the father. The PACU nurse stated that the patient’s father verbalized understanding of the discharge instructions and left with the patient. The medical record lacked documentation of this encounter. The medical record also lacked documentation of any
Review of the medical record for the specified patient (SP) was completed 09/16/12. The medical record revealed that the SP was a minor child with a diagnosis of history of frequent and recurrent tonsillitis and was scheduled to have the tonsils and adenoids removed 09/14/12 at 10:30 AM as an outpatient procedure. Review of the medical record for the day of 09/14/12 revealed that the SP was admitted to the pre-admission testing area at 9:00 AM. At 10:00 AM the SP was in the pre-operative area with the peripheral intravenous line in place and the pre-operative medications were being administered. At 10:30 AM the SP was in the operating room (OR) and the procedure was performed as scheduled. At 11:15 AM, the SP was moved from the OR to the post anesthesia care unit (PACU). At 12:15 PM, the SP was successfully recovered from the procedure and both the surgeon and the anesthesiologist cleared the SP to go home. The medical record revealed a nurse’s note by the pre-operative nurse on 09/14/12 at 10:30 AM that documented a conversation between the pre-operative nurse and the SP’s mother where the mother stated she was leaving to run an errand involving an older sibling and left a cellular telephone number. The only documented instruction from the mother was for the nurse to call if the SP got out of surgery sooner than expected. In an interview with the PACU nurse conducted on 09/15/12 at 10:00 AM, the PACU nurse stated that on 09/14/12 at approximately 12:30 PM, the patient was released for home to her father, who was identified by his driver’s license; the PACU nurse stated that she provided written instructions for the patient’s post-operative care and follow up appointment to the father. The PACU nurse stated that the patient’s father verbalized understanding of the discharge instructions and left with the patient. The medical record lacked documentation of this encounter. The medical record also lacked documentation of any