Tina Imbalt Case Summary

3 year old Tina Gerhardt was admitted to the abulatroy surgery unit at Nightingale Community Hospital by her mother for bilateral myringotomies (insertion of ear tubes). After Tina was registered, she was handed off to the pre-op nurse and she explained that the surgery was going to take 45 minutes and recovery would take an hour. Tina mom gave the per-op nurse instructions to called her if Tina was done with surgery and recovery before she came back. The per-op nurse took the information down in her personal note pad but failed to pass the information on when she handed her off to Rosemary the nurse. Rosemary was unable to pass the message on to the discharge nurse because she did not receive anything or message from the pre-op nurse. Tina’s mother returned two and a half hour later and found that her child was discharge 30 minutes earlier. Security was called and code pink was also called. The local police department was notified but security. Tina was located within 30 minutes of the mother returning back to the clinic by the local law enforcement in the care of her father.
From registeration, there was a failure to get Tina's mom information or identification.
It seems as if the only thing that the hospital care about is the insurance and the demographics. The safety of the patient should be one of the top priorities. One improvement would be for the hospital to put something in the registration charts about who the patient should be released to and take the identifiation of the person registrating the child. This release should travel with the child during every step of way with a minor. when the child registers, the hospital should implement a wristband that can be scan for the parent and the child and if the parent does not have the wrist band, they cannot leave with the child unless identification is
presented.
It seems like everyone was passing the buck instead of taking responsibility for their actions and implementing a safe turn over from parent to hospital staffs. Yes, there needed to be a policy in place but since there was no policy; staff could have implemented some unofficial standards u that they could use amongst themselves.
The discharge nurse did not bother to get any type of identification from the father. All she needed to know was that the child called him daddy and was happy to see him. The nurse should have checked which parent or guardian registered the child and called that parent to see if it was ok to discharge Tina to her dad. As a matter of fact, verbally authorization should never be allowed. Only written authorization should be allowed with proper identification. Anyone can say that they are the parent or guardian and sometimes a young child does not know who is safe and who is not. When the discharge nursed said that it did not occur to her to find out about the custody that means the hospital really need something in place that would help handing off a child to the correct parent.
Chief Nursing Officer Anna was not involved in the incident but she is in charged of all the nurses. She realize that there is a breakdown in communication with nurses and would like to help in changing the breakdown. Anna needs to find out why there is a breakdown in communication with the nurses and is she apart of the breakdown in communication. One suggestion would be for the nurses to be involved in team building training where they could bond with the nurses and realize that passing on information is vital to the success of the hospital and patient safety and satisfaction. The nurses can also come up with suggestions about what would make communication better such as adding some more forms at registration or with the pre-op nurse. M aybe the Chief needs to hire some more nursing so that the nurses can take the appropriate amount of time they need with the patient.
The pre-op nurse sounds like she was over work and the things that she needed to make her easier, she had to spend 15 minutes looking a for a gown. Area of improvement is that that hospital put something in place where surgery patients gown can be found easily. Pre-op nurse sounds like she is burned out or she just does not enjoy her job anymore. She did not see how adding anything fir her to do would change the situation. Maybe pre-op nurse needs to work in a different department or change her outlook on things. She did have a great suggestion for the hospital to put wrist band on both the child and the parent. She also thought that something needed to be added to registration about who the child can be discharge to. She also points out that the doctors office does not provide the relevant information that the hospital needs. One suggestion would be for the doctor to give the relevant information for patients before surgery.
Rosemary is saying that this type of miscommunication happens all the time and it would be nice to see all the departments comminicating. Rosemary just wants to be proactive in the solution and saying that there is a problem that needs to be fixed in the entire hospital.
Jon the recovery nurse sounds like one of the nurses that do not like changes. He thinks the old system works better and he probably minimize how many children this had happened to. He needs some motivation and he is talking about another nurses experience and not his own. He needs to be willing to try new things or policy and procedures.
Tim the security is absolutely correctly in that the staff should have contacted him before 25 minutes. The staff immediate response should be to contact security immediately to see what can be done or who he needed to alerted. He is also correct that they need a policy and procedure in place to help this error from occurring. Checking every arm band is a little too much for the security. The discharge nurse just needs to make sure everything match up with the parent and the child.
Carlos the Surgeon seems like he wanted someone to blame someone for this situation. He needs make sure his office send over the proper paperwork for his patients or send it in a package with the child’s parent when they are having surgery. That is how Carlos can ensure that his patients are safe and bring up the issue with the hospital supervisor so that they can change the policy or put something in place. He was doing a generalization of the situation and the hospital staff would not have known that Tina’s parents were divorce unless someone told them about it or it was in their paper work. He is absolutely correct about the hospital having legal ramifications for neglect for letting the child go with anyone.
The entire hospital will have child abduction retraining 4 times a year to ensure that they know that proper procedure and just to refresh them on the procedure.
Staff will have random observations of each unit that deals with children to find near miss situations. If staff does not follow the procedure, use it as teachable moments. The department supervisor will be the person for his/her staff to go to if they are having trouble with the policies and procedures for child abduction. If they policy and procedure that is in place not working, staff will take it to their supervisor and the supervisor will bring it to the hospital head supervisor. All the supervisors will have a meeting to revise the child abduction policy.
The head supervisor can put in place the same policy they use for OB in all departments to keep all children safe and to eliminate the various uses of different child abduction policy in the same hospital. Tim suggested some great ideas about doing hospital wide drills to see the hospital response. The hospital will do random drills for the first two years to make sure staff is following the policy correctly.
A2. Describe the Roles
A3. Barriers Improve Interactions
A4. Quality improvements
B. Corrective action plan Risk management