Sentinel Incident Case Study

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1. A sentinel event is defined by The Joint Commission as an event that results in unanticipated death or major loss of function not related to the natural course of a patient’s condition, or one of several other specifically defined circumstances that do not necessarily result in death or major injury to the patient. The term “sentinel” is used to emphasize the need for immediate investigation and response. (The Joint Commission, n.d.). The abduction of a patient receiving care, treatment and services is one of the specific circumstances The Joint Commission considers a sentinel event.

The sentinel event that occurred at Nightingale Hospital was an abduction of a patient by the non-custodial parent. The patient is a
The officer’s role is to secure the environment and assess the situation to determine whether additional resources are needed. The officer investigates events related to safety and security of patients and staff and makes recommendations for improvements to avoid unsafe or dangerous situations.

Chief Nursing Officer: The CNO was not present at the time of the event. The CNO’s role is to oversee all aspects of nursing care in the organization, and to put policies and strategies in place to ensure that patients are cared for in a safe and effective
Forms |
| |custodial parent/legal guardian | | |Committee for approval. |
| |who the patient will be discharged home with | | | |
|Pediatric Registration |Begin printing identification band(s) for parent/guardian as |Registration leadership, |Within two weeks |Risk Manager, Educators to |
| |well as patient. Ensure bands are applied to identify persons|nursing leadership | |train staff on new process