Sentinel Event Analysis

Running head: NIGHTINGALE COMMUNITY HOSPITAL SENTINEL EVENT

Sentinel Event: Child Abduction
Nightingale Community Hospital
Greer Elizabeth Unruh
Western Governors University

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Communication is the be all and end all in a successful corporation. Nightingale Community Hospital was unfortunately lacking in this department when Tina, a child who was about to be discharged, was thought to have been abducted from the vicinity. The personnel in charge of Tina’s wellbeing at that time all gave their opinion of what happened and what preventative measures could have been taken. Tim Blakely, security officer, is in charge of securing the premises of the building and ensuring that all patients are protected from outside harm. At 9:00 AM,
Tim received a page regarding a potential abduction of a small girl. He immediately made his way to the ambulatory discharge center to speak to the nurse that was supposed to be watching the girl. The nurse had known that Tina was missing for at least 25 minutes, and Tim was frustrated that he had not been alerted as soon as possible. He made a mental note to prepare a hospital wide memo clarifying that there is to be no delay whatsoever if a child is reported missing from the facility. Confusion blooms from inconsistency of rules; if the policies regarding child abduction are not uniform, there is no smooth way of responding appropriately and immediately. Tim believes that child abduction drills would benefit the hospital employees. Strict rules should be enforced in order to guarantee patient safety, such as delegating wrist bands to every person admitted to the hospital and checking every wrist band at the time of discharge. Security guards are hired to protect, and it would be easier to do so with the compliance of all other hospital personnel. The registrar, Katie Jessup, entered Tina’s information into the registration database when she and her mother checked in. It is not part of the process to ask the patient and guardian for additional identification or ask for elucidation concerning custody of the child. Katie did not have a lot to say except for that she believes it to be the nurse’s responsibility to make sure that the patient goes home with the correct parent or guardian. The duties of the registrar are to acquire all necessary medical and personal information and create a chart that will follow the patient to every area of the hospital he or she will end up at. This chart ensures that the patient receives the right types of medication, highlights any adverse effects to drugs, and lists all potential warnings and previous ailments so that all doctors that come in contact with the patient are on the same page.
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3 The Chief Nursing Officer is the individual who resumes all responsibility for the actions of all nurses in the hospital. Anna Liu-Dilarno, Chief Nursing Officer at NCH, was not physically present for the sentinel event, and although she was not involved, carries the burden of the event because of her high position. She admits to there being some problems in communication between nurses, mostly concerning information that is overlooked and consequently is not entered into the patient’s file. Anna wants to do all she can to ensure the best nursing care, and to do that she must make sure that the flow of information is done properly and without a hitch. The OR nurse, Rosemary Fry, believes that each department is looking after their own interests in this case and nobody wants to take the blame. She says that there needs to be better communication between departments, which is the obvious conclusion, and states that this is a recurring problem that affects the hospital in other ways. Rosemary is responsible in seeing that pediatric patients are taken care of in the operating room during surgery and then transfers the patient to post-operative care, which is exactly what she did. Carlos Munoz, a surgeon at NCH, sounded very upset and enraged in his interview.
He is dumbfounded that this sort of situation could happen to one of his patients and blatantly blames the nurses. He questions their intelligence, asking how they did not know that the girl’s parents are divorced and only the mother has custody. The father is not allowed to take his daughter due to legal rights, and big legal issues are involved with inattentive behavior. Dr. Munoz is the number one ENT for outpatient surgeries at Nightingale and is afraid that with his neck on the line for this casualty, he will lose credibility. Surgeons are responsible for the medical operation itself, as well as making sure the patient gets from pre-operative care to surgery to post-operative care safely. In these regards, Dr. Munoz did his job, but is still unhappy with the negligence of the nursing staff. His office notes state who the custodial parent is, but the staff did not ask for his notes. One way of avoiding this mess and covering his tracks would be to make certain that all notes taken by all medical personnel are transferred onto the patient’s record so there is no
confusion.
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4 Kim Johnson, the discharge nurse who oversaw that Tina went home with her father when she was not supposed to, seems to be deeply apologetic. When the recovery nurse brought Tina to her, the little girl was very anxious to go home and her mother was nowhere to be found in the waiting area. Kim was unsure of what to do and said that Tina was “so cute” and “doing so well” and was all in all ready to see her mom. Tim, the security officer, called and said that Tina’s father was at the main reception, and when Tina saw her father she became physically relieved. After 30 minutes of waiting for her mother, her father offered to take Tina home and Kim obliged. Discharge instructions were given and it did not even cross Kim’s mind that the father might not have custody given the positive interactions between him and his daughter. When Tina’s mother arrived, she was extremely upset at the situation. There needs to be a better job done of screening everybody that enters the hospital so that misunderstandings like this can be avoided.
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5 Tina was handed off to Jon Peters, a recovery nurse, for post-anesthesia care. After Tina’s surgery was finished, Rosemary brought her to Jon for post-operative care and gave him a report about how the surgery went. Jon went to the waiting room and called out for Tina’s mother and got no reply. Recovery nurses are in charge of restoring the patient’s health and spirits after being operated on, and he was doing just that until it was time to bring Tina to Kim for discharge. Jon mentioned that he does not have any ideas on how the system can be improved. He has a friend who works for Benjamin Memorial Hospital and they have a very intense and formal handoff procedure that Jon says seems like a hassle more than anything, because they are so busy on the computer that they are unable to spend any quality time with the patient. Realistically, NCH should take notes from BMH and implement an official handoff system so that situations like child abductions do not occur. A few extra minutes being cautious could save the hospital a lot of trouble. Greta Doppke, the pre-op nurse, did everything her job description asks of her in preparing Tina for surgery. She was very defensive and claimed that the nursing assessment form did not ask the nurses to confirm who has custody. Greta also asserted that the nurses never get any information from Dr. Munoz’s office, so they had completely different information than him. After preparing Tina for surgery, Greta took her to the OR and handed her off to Rosemary. She thinks that wristbands should be worn not only on children patients, but on their parents as well, for identification purposes. The nurses are so busy each day that she does not see how changing the procedure in any dramatic way would be beneficial.
Successful interpersonal interaction between hospital patients and medical personnel is vital on many accounts; the patient is more content with the treatment he or she is receiving, observance of treatment is carried out more effectively, and the overall health of the patient is better. When a patient comprehends what his or her illness truly is, compliance is more often reached regarding treatment plans and healthcare regimens (Care for Human Services, 1999). With a higher level of organization, interactions can be vastly enhanced and fewer mistakes will be made. Fewer errors made by medical personnel results in satisfied patients and supervisors, which in turn elevates the mood in the hospital through and through. When a patient’s information is laid out simply and everything is clear, it removes a significant amount of potential oversights from occurring.
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6 NCH employees need to take a look at the mistakes that are happening, think about the consequences of these missteps, and create a solution that will not jeopardize the health of the patient.
The obvious problem is lack of communication, which was pointed out by nearly every employee involved in the sentinel event. The most effective way of making sure this does not happen is to create a risk management plan that begins the minute the patient walks in the door. NCH should create a protocol where the registrar takes down all information, including anything regarding custody of the child and who is allowed to pick up the underage patient. A code can then be administered to each family and wristbands can be printed with that code, and if the person picking up the child at discharge does not have the same bracelet, then he or she is to remain in custody of the discharge nurse until the legal guardian of the child (or any adults that were predetermined by the dominant guardian to facilitate the pickup)
arrives. Step two in the risk management plan would be to accumulate any notes taken about the patient and make them visible to all medical personnel working with him or her. Any notes taken by the registrar, nurses, doctors, or any other staff member must be entered into the patient’s file so there is no information left out. Each time a patient is handed off to another healthcare professional, there should be a formal procedure so that whoever is taking care of the patient assumes full responsibility and is liable for anything that may happen to him or her in the time that they are providing care. With technology being so advanced, this system could easily be computer based. Essentially, a liability form needs to be signed so that the caretaker is held accountable while in charge of facilitating medical needs.
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7 If this protocol is followed from start to finish, there should not be any confusion in who is picking up the underage patient from the discharge center. This is a very simple system, and although it might take some time to develop, it should be very easy to execute. Patient safety is the crux of every hospital’s mission, and taking extra precautionary steps could put a stop to any child abduction or other casualties that could occur due to negligence. The main resource that would be necessary in order to establish this protocol would be a database that the healthcare professionals would have to sign off on in order to move onto the next step with the patient. Whenever a patient needs to be transferred from one area of care to another, this database needs to be accessed before any subsequent care can take place. It is important for this list to be computerized so that a higher authority can grant approval; if done on paper, signatures can be forged and care is compromised. There needs to be two signatures for every pass-off, one from the previous nurse and one from the person who is going to assume the role of the patient’s primary healthcare from that moment forward. If two signatures are not captured, consequences will be implemented. The initial pass-off signature belongs to the patient’s parent or guardian (assuming the patient is underage), as well as the ultimate signature to ensure that the he or she is safely in the care of his or her appropriate guardian. This procedure will guarantee that the child will be supervised at all times and there will be no room for discrepancy.
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8 The tagging system described earlier would help medical personnel identify which adult belongs to which child. If the parent and child have matching bracelets with the same code on them, it puts the discharge nurse at ease when releasing the patient from the hospital. Still, the database would require both the guardian’s and the caretaker’s signature at the time of release, but a visual symbol is effective and reassuring. If Nightingale Community Hospital becomes more orderly and strict in their patient care procedure, instances like this sentinel event will be few and far between. It is imperative that the hospital keeps track of its patients, particularly children. Nurses, doctors, and all medical personnel alike should be responsible for knowing the patient’s medical history, as well as concerns of the patient’s wellbeing. It is unacceptable to discharge a child from post-operative care with a person who is not his or her guardian. With the help of a meticulous handoff procedure, NCH should never come across this problem again, and all patients (as well as parents) can rest assured that they are receiving the best medical care available.

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Sources
Care for Human Services. (1999). Improving Interpersonal Communication Between
Healthcare Providers and Clients. Retrieved from http://www.hciproject.org/sites/default/files/Reference%20Manual_1.pdf