AFT2
Task 2
A1. Summary of Sentinel Event A recent sentinel event occurred at Nightingale Community Hospital involving the possible abduction of a 3 year old patient. According to the Joint Commission, a sentinel event is one that is unexpected and results in death or serious injury (2015).
According to the documents and interview provided, a child Tina was admitted into the hospital on September 14th by registration. Insurance and demographic information was collected by registration. The patient then went to pre op with his mother for outpatient surgery. The pre op nurse then prepped the patient for surgery by having the mother sign the consent form, changing into appropriate surgical attire, and starting the I.V. The pre op nurse told the mother the procedure would take about 45 min and then the patient would be in recovery for at least an hour. The mother had to leave to take care of an errand with her other children and had left her cell phone number with the pre op nurse. She instructed the pre op nurse to call her if her daughter was done sooner. The pre op nurse put down her number in her notebook.
After the completion of the surgery, the patient was taken to the Post Anesthesia Care Unit (PACU). Upon arrival in PACU, the mother had not returned. The patient was becoming uneasy that her mother was not back, the PACU nurse had the mother paged on intercom but it was determine that she had not returned. The patient was then transferred to the discharge nurse who was informed that the patient’s mother had not responded to the pages. Several minutes later the discharge nurse was notified that the patient’s father was at main reception. She let him come back and the patient immediately recognized him as her father. After 30 min he offered to take the patient home and the discharge nurse approved that. He was given discharge instructions.
The patient’s mother returned 2 ½ hours after leaving initially to find that the patient was discharged 30 minutes prior. Becoming extremely distraught, security was notified and a “Code Pink” (hospital wide child abduction alert) was activated. Local law enforcement was also contacted. The patient’s mother shared with security that she had full custody of the patient and her siblings.
The patient was found 30 minutes of her mother’s arrival by law enforcement. She was in the care of her father, who had taken her to his home to await the arrival of her mother. No charges were filed against the father.
A2. Roles
Registrar –According to the interview, the responsibilities of registration included the request and collection of insurance and demographics. These are then entered into the EHR. Also she requested the Condition of Admission Treatment form which was signed and filed into the patient’s chart. There is no policy to ask any additional information regarding custody.
Pre-op Nurse – The pre-op nurse is responsible for prepping patients for surgery. In addition to completing the Pre Op Nursing Assessment form, the nurse has the patient change in to gowns, starts IV, administers medication, and has the patient or patient’s guardian sign the consent form. Then when ready the pre op nurse transfers the patient to the OR nurse.
Security – Responsibilities of security involved initiating a code for child abduction. Security is responsible for screening the hospital for security issues such as the child. Security also interviewed the staff and patient’s mother. Security is responsible for contacting local law enforcement. Security currently only performs child abduction drills in OB department.
O.R. Nurse – Works with surgical staff in the OR. Receives patient from the pre-op nurse for surgery and then transfers the patient to the recovery (PACU) nurse.
Surgeon – Responsible for performing the surgery. No other responsibilities identified. Surgeon did document in chart note regarding custody, chart note was not provided to or requested by the hospital.
Recovery Nurse – Receives the patient from the OR nurse when surgery has been completed. The recovery nurse provides post anesthesia care until the patient has fully recovered and suitable for discharge, then care is transferred to the discharge nurse.
Discharge Nurse – Responsible for care of patient once transferred from recovery nurse. The discharge nurse ensures that the patient and parent get proper discharge instructions.
Chief Nursing Officer – In the interviews, the CNO stated she was responsible for all nurses in the hospital. This also would imply that she would be a part of the process for finding a solution and making sure implementation of policies occurs. (Not actually present during the event).
A3. Barriers
Some of the barriers that may impede effective interaction between staff include a lack of communication, differences in knowledge or experience, and understaffing. Communication is essential for effective interaction, whether it involves documentation in patient charts or even direct communication between staff members. Personnel must communicate with one another in order to effective work as a team. Another barrier may be differences in education or experience among staff. Staff that are not as experienced as other staff may not ask the same questions or recognize problems that experience staff might. Also staff that may be highly experienced may not be educated in recent developments or changes. These differences may clash if not properly approached. Understaffing is a large barrier that may cause ineffective interaction. Staff that is overworked may become stress and even rushed. Becoming either of these can negative effect the interaction with others.
Ways to improve interactions among the personnel that was present is to implement procedures that require more communication between staff. An example of this would be to implement a patient hand off form. It would include all necessary demographic information (including custody) and contact numbers provided at registration and have sections for the staff to add notes about the patient that may not have been recorded previously.

Another example would be to implement mock drills and frequent training at least quarterly or annually that could help keep all staff current. Meetings are a great way to bring minds of different experiences together collaborating ideas and prevent confusion among the staff.

Lastly, understaffing is a serious problem and should always be avoided. Staff minimum requirements should always be met to prevent slips in patient safety. Having an on-call staff list that available and utilizing it is important. In addition, private contracts with personnel companies can also provide backup staffing in emergent cases.
A4. Quality Improvement Tool
A quality improvement tool that may be utilized to conduct the root cause analysis would be the Plan-Do-Check- Act Procedure. According to ASQ, this procedure is used for a continuous improvement and when starting a new improvement project (2015). The first step of this procedure is to plan. Acknowledging an opportunity and making a plan to change. Then Do, test the change in a small scale or in a study scenario. Next, Check or review the test and analyze the results. Discuss the results and what has been learned. Lastly, Act or take action on what has been learned. If it didn’t work, start the procedure again, if it did work, then the change can be implemented on a larger scale and continuous improvement s can be made by repeating the procedure.
B. Process Change
An easy method of preventing the sentinel event from occurring would be a process change.
A policy should be created for a patient hand off form that would stay with the patient from the time they check to registration. Such form should be filled out if there is any pertinent information that is not already in their electronic records. Each nurse who sees the patient should complete their section of the form prior to handing off to the next. The nurse should review and initial each prior section to indicate they have reviewed it. If there is nothing to new to note they should write “None” in their note section and initial prior to hand off. According to the Patient Safety Network, the implementation of a standardized handoff bundled markedly reduced the incidence of preventable adverse events associated with handoffs (2015).
In addition, the registration process should implement more information required at registration. This should include emergency contact numbers, all phone numbers, custody information of children, and even information such who can take children home other than the parent checking them in. This information should be signed and dated by the patient’s guardian then entered into their electronic record and filed in their chart.
Policies should be changed that any visitor who is seeing a child must have their ID checked and a wrist band should be given to them with the visitor’s name and the patient name on them. Prior to letting any child leave with a visitor, the name on the band must match those provided at registration.
Resources
The policies should be created by the CNO and be approved by leadership team. This should occur no later than 45 days. Once the policies are approved, Education department will be responsible for training staff on all new policies no later than 30 days of the approval. Policies should be implemented no later than 90 days. The quality improvement tool should be utilized by the Compliance Department and should be reviewed after 90 days of implementation. Any changes that may need to occur must be reviewed prior to implementation of new changes.
Sources
Joint Commission Standard. (2015). Sentinel Event Policy and Procedures. Retrieved from http://www.jointcommission.org/sentinel_event_policy_and_procedures/
ASQ. (2015). Plan- Do-Check- Act Cycle. Retrieved from http://asq.org/learn-about-quality/project-planning-tools/overview/pdca-cycle.html Patient Safety Network. (2015). Handoffs and Signouts. Retrieved from https://psnet.ahrq.gov/primers/primer/9/handoffs-and-signouts