Sentinel Event:

Sentinel events are a subset of medical adverse events. Events that require immediate attention are called Sentinel Events. Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Sentinel Event identified by Joint Commission also include infant abduction or discharge to the wrong family.

Summary of the Sentinel event in the Case Study:

Sentinel event presented in the case study involves discharge of a minor to the wrong family. Joint Commission requires immediate attention to such matters so that it may be avoided in the future. The summary of the event is that a 13 year old teenager, Tina, was admitted for day surgery. Tina was accompanied by her mother. After dropping Tina for the surgery at the hospital, her mother left to run some errands. Before leaving, she left her contact phone number with the pre-op nurse. After the surgery, Tina was inappropriately released to her father when her mother was delayed in returning to pick-up the daughter from the hospital.
The hospital staff had no awareness of the family situation. Upon arrival at the hospital after the errands, mother was informed that Tina’s father had picked up Tina from the hospital because the mother was 2 ½ hours late in picking up Tina. The hospital staff had attempted to contact the mother multiple times prior to releasing Tina. According to the call logs, six attempts to contact the mother were made by the post-op nurse in the 45 minutes the mother was delayed in arriving. At that time, mother informed hospital that it was not acceptable that Tina was released to her