A1. Sentinel Event
On the evening of September 14, 2011 a sentinel event occurred at Nightingale Hospital. According to Joint Commission, a sentinel event is characterized as an unexpected occurrence involving death or serious injury mother proceeded physical), or the risk thereof (http:www.jointcommission.org).
A three year old child was accompanied by her mother for an outpatient procedure scheduled for September 1, 20111. The mother proceeded to register the child for the procedure and was provided details regarding anticipated length of surgical time and physical assessment. The pre-operative nurse was informed by the mother of the child that she needed to run an errand but left contact info(i.e. cellphone number) with the child’s nurse in the event the surgical procedure was to end sooner than expected. Unfortunately, the pre-operative nurse did not chart this pertinent information in the patients chart, it was documented on a sticky note attached to the chart. Post-surgery, the child was taken to the recovery area with care assumed by a recovery team without sight of mother. The father of the child presented to the recovery room and began hugging the child and was able to verify child’s name, date of birth, and was listed on face sheet in chart as father of the child with proper identification. Discharge instructions were provided to the father and the child was released in the fathers’ care. Approximately two and a half hours later, the mother arrived to the unit to assume care for the child and was notified that her child was released in the custody of her father. Mother became extremely upset and flustered and began disclosing that she is the custodial parent and that they are divorced. Security personnel was immediately notified and a hospital “code pink” was issued over the intercom. According to Nightingale Hospital policies and procedures, a code