Accreditation Audit (AFT2) Task 2
A1. Sentinel Event Summary
This sentinel event is directly associated with a child abduction at Nightingale Community Hospital. A 3 year old patient was having surgery at Nightingale Community Hospital on Thursday, September 14. The patient’s mother accompanied the patient before surgery and completed all consent form. An estimated time of 1 hour 45 minutes was given as the time to complete surgery and recovery. The mother informed the pre-op nurse that she would be off campus during the surgery and would return to pick up the patient in the time frame given. She also provided a phone number to contact her if the procedure was finished earlier than planned. Upon completion of surgery and recovery, the patient’s mother was paged from the waiting area by the recovery nurse. The mother was had not returned to the hospital at this time. The patient care was then transferred to the discharge nurse while waiting for the mother to return. During this time the patient was very upset and crying for her mother. The discharge nurse was notified that the father was in the waiting area and approved for the father to see the patient. The father was with the patient for about 30 minutes and the mother had still not arrived. At that time, with no specific information about the patient’s custody arrangement, the discharge nurse provided the father with discharge instructions and allowed him to leave with the patient. When the mother arrived to pick up the patient, she was very upset that the patient was released with the father who does not have custody over the child. Hospital security and law enforcement were notified and a “code pink” was activated within the hospital (child abduction alert within the Hospital). The child was located by law enforcement at the father’s home waiting for the mother to return. The patient was returned to the mother without incident and no legal charges were filed.
A2. Personnel / A3. Personnel Issues / A3a. Improve Interactions
Hospital personnel involved in this sentinel event involve the below individuals along with their roles. Additionally barriers of interaction will be highlighted in each role along with opportunities to improve on these interactions.
* Registrar: The registrar is the initial individual working with the patient and their family to check them into the hospital. The current responsibilities include entry of patient demographics and insurance information. The registrar also ensures proper authorization forms are completed to complete the procedure and for payment requirements.
* Personnel Issues: The information gathered by the registrar does not include any detail to identify patient custody or specific identification requirements to assist in the discharge of the patient. In addition, there is no access or communication from the surgeon’s office notes with the hospital registrar to identify if any additional information is available to ensure patient safety.
* Improve Interactions: The registrar process includes 3 key functions that can help improve interactions with the patient, family, and internal hospital staff.
* Custody identification