Sentinel Event: Child Abduction
Description of Event A three-year-old patient presented to the hospital for outpatient surgery of bilateral myringotomies with mother. After the patient was registered, consent for surgery signed by mother, and prepped for surgery, the mother gave the pre-op nurse her phone number and left to run an errand with instructions to be called if her daughter was finished with surgery sooner than expected. The mother was expecting the patient would be ready to go home in about 2 hours. The pre-op nurse stated that she wrote down the mother’s phone number in her own notepad to call her. The patient completed surgery and was taken to recovery. At this time the recovery nurse paged out to the waiting room for the mother as parents are encouraged to come back to the recovery area as the children come out of anesthesia. With no answer from the page and the patient awake and stable, the patient was then given to the post op nurse for discharge. The post op nurse stated that the recovery nurse had tried to page the mother, but made no mention of trying herself. The patient was becoming upset because she had not yet seen her mother. The security personnel called informing the nurse that the patient’s father had arrived and the patient happily met the “father,” so the discharge nurse waited another thirty minutes before releasing the patient to the father as there was no sign of the mother. When the mother of the patient arrived thirty minutes after the patient had been discharged looking for the patient, security was called, an internal code pink was initiated and law enforcement notified. Security stated that the mother informed them she had full custody of the patient and that the parents were divorced. The patient was found within thirty minutes in the care of the patient’s father at home. No charges were filed against the father.
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