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Kelly
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AFT Task 2
Thursday, September 14th at 12:30pm, a three year old female (Patient GERHARDT,
Tina) was brought into the Ambulatory Surgery Unit (ASU) at Nightingale Community
registering patient, pre-op nurse called them to the pre-op area to be prepped for surgery.
The pre-op nurse informed the child’s mother that once patient went into the OR, her
Patient’s mother informed the pre-op nurse she would be leaving the hospital as soon as
her daughter went into the Operating Room but would be back by the time she was out of
recovery to pick her up. The mother gave the pre-op nurse her cell phone number and
requested that she be contacted if her daughter was to get out of surgery earlier than
expected.
Approximately 2 ½ hours later, the patient’s mother returned to the hospital. Her
daughter (patient Gerhardt, Tina) had been discharged 30 minutes prior to her arrival.
Security interviewed the mother. She shared that she is divorced from the patient’s father.
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Patient was located in the care of her father by local law enforcement within 30 minutes
of mother’s arrival. The father had taken the patient to his home to wait for the mother’s
arrival.
CEO of Nightingale Community Hospital told mother there would be an analysis of the
incident with processes put into place to prevent a similar event from being repeated.
Role in Sentinel Event: Was not present at the sentinel event but recognized that there is
problems with communication among the nursing staff. She also expressed that there is problems
ensuring that the nurses have entered information into the system.
Registrar- key patient service support; First point of contact. Responsible for entering
Role in Sentinel Event: Followed protocol for registration by entering in pertinent information
into the electronic medical records (EMR), requested copy of insurance card and had proper
Registrar did not verify identification of patient or mother. Custodial care was not questioned.
Neither pertinent pieces of information are included in the routine registration/admission forms
Pre-Op Nurse- Responsible for preparing patient for surgery. Completes pre-operative
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of preparations into the EMR, and has the Informed Consent form signed by patient or
guardian.
Role in Sentinel Event: Followed protocol and policy for completing pre-operative nursing
assessment and documentation. Neglected to further document into EMR mother’s cell phone
number and directions for pick-up. Legal custody and guardianship identification were not
addressed as this is not prompted on the pre-op assessment or EMR assessment frame.
OR Nurse- Responsible for receiving patient for surgery in the operating room, cares for
patient before, during and after surgery, works along-side the surgical team, and serves as a
Role in Sentinel Event: As per the Pre-Op Nurse, received patient at point of operating room.
Recovery Nurse- Responsible for providing patient post-anesthesia care, takes patient’s to
Role in Sentinel Event: Provided patient with post-anesthesia care. Received surgery report from
OR Nurse. Paged mother in waiting area once patient was awake. Mother was not present in
waiting area. Transported patient to the Post-Operative Area for discharge once patient was fully
recovered.
Discharge Nurse- Responsible for establishing patient referrals with health care services,
gives written conveys doctor’s orders for after care, medications, and treatment, then
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Role in Sentinel Event: Received patient from Recovery. Recovery Nurse communicated that
patient’s mother could not be located in the waiting area. Received call from Security stating that
patient’s father was at main reception. Allowed Father into Post-Operative area for discharge to
see daughter. Discharge Nurse felt it was identification when the patient recognized the man as
her father. Father offered to take patient home after waiting 30 minutes for the mother. Discharge
Security- Responsible for performing infant abduction drills; activating Codes that involve
Role in Sentinel Event: Responded to potential child abduction call from the Ambulatory Surgery
Unit’s discharge area. Interviewed the Discharge Nurse. She stated patient had been missing for
approximately 25 minutes. Activated a “Code Pink” and called the local law enforcement.
Surgeon- Responsible for performing pediatric ENT surgery, forwarding pertinent patient
office notes and admission orders to proper departments at Nightingale Community Hospital,
Role in Sentinel Event: Surgeon’s patient office notes were not sent to hospital that stated the
Organizational barriers were impeding effective interaction among personnel who were
directly involved in the Sentinel Event. Confusion and obstructions occurred in the
communication process as a direct result from the poor definition of the staff’s roles within the
hospital’s system. From the first point of patient contact, to the discharging of the patient with
the wrong parent, each staff member believed that the task of identifying guardianship and
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properly documenting start to finish notes on patients were the responsibility of someone else.
Because the organization lacked policy, procedure, and a written protocol, staff simply set aside
the responsibility of patient identification and safety. Then, individual staff members assumed
that someone else would perform the necessary steps rather than ensuring that someone accepted
followed along with extensive training and clarification of personal roles and responsibilities.
Further, a change in the organization’s culture to embrace a team player atmosphere would
Organizational barriers directly attributed to poor operational skills caused by the lack of
procedures that would have helped to define and direct a process for an appropriate line of
communication. The unfortunate result was the absence of understanding what other departments
operations were responsible for. The involved staff clearly were without a level of appreciation
and comprehension of individual personnel’s roles. Thus, unrealistic demands were placed on
each other. In order to improve and avoid the confusion and misinterpretation, employees should
be trained in awareness in regards to the functions of other departments and the responsibilities
of external health care providers. Personnel should place ownership to following up on minor
Hospital staff must have an appreciation and understanding of what roles each department of the
hospital plays within the process in order to effectively communicate with one another.
Moreover, an inappropriate communication tool was used by a staff member. The recording
of key information for patient care and safety was documented inside a caregivers pocket
essential component of excellent, effective interaction among personnel. In the given Sentinel
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Event, it would have required more than one communication tool to deliver the correct level of
urgency and importance for the parent’s message. To improve the involved staff’s interaction,
the caregiver should have communicated face-to-face to another co-worker on that shift. Next,
the information should be documented into the patients EMR. This duty should take top priority.
Then, the department receiving the patient should be called and the information given verbally to
follow-up on the updated documented EMR information. At this point of contact, security should
be advised to the name and identification of the minor’s legal guardian along with the pertinent
information for a secure pick-up and discharge. Each department is an integral link to effective
Because of their ability to visually lay out the sequence of events that lead to a Sentinel
Event, Flow charts followed by a Cause-and-Effect Diagram are excellent quality improvement
tools to use to conduct a root cause analysis. Flow charts boast the capacity to expose deficits
and obstacles in the process that might be preventing a smooth course of action. Then, using the
steps from the Flow Chart, the Cause-and-Effect diagram can be created to categorize the
discovered information to show relationships between the exposed causes and effects leading to
Flowcharts are chosen for root cause analysis because they are easily read by the lay-out of
standard symbols that point-out the beginning or end, the process being conducted, and the
decisions being made. Moreover, symbols help breakdown the events to many sub-processes
allowing for a clear analysis and discovery of unseen problems. Once the information is
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Cause-and-Effect Diagrams are chosen and used for root cause analysis because they
categorize the event’s causes into major branches connected to the central backbone line to the
diagram allowing for further brainstorming. When all the contributing factors are categorized a
fishbone structure develops and the facets of the problem can easily be seen. Typically, the main
issue is written at the beginning of the diagram with the branches identifying the causes related
Flow Charts and Cause-and-Effect diagrams were chosen for the root cause analysis because
of their quality to allow all those involved, the ability to see the event in the same way. Thus,
Action Plan
Root Cause(s)/Opportunity for Improvement(s):
a. Poor definitions of department/individual roles and responsibilities. Create an
environment that makes every step of patient care the obligation of all personnel.
b. Standardize an approach to “hand-off” communications, including an opportunity to
ask and respond to questions.
c. Absence of a well-defined Security process for pediatric patients. Including
a verification process for guardian identification
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Director of Nurses
Human Resource Training Specialist
Target date of implementation:
6/25/2016
Location of implementation:
Extended Hospital Meeting Room
Completion date:
7/15/2016
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Compliance Committee
Project Manager
Target date of implementation:
6/30/2016
Location of implementation:
Surgical Departments
Admitting Department
Nurses Stations and Patient Rooms
Healthcare areas where key patient information is processed
Completion date: 7/15/2016
Measures of Effectiveness/Performance Indicators:
Director of Nurses will monitor and watch over implementation and competencies of licensed
staff using standardized forms and communication process. Audit tool will be used for staff
assessment in communication process. Compliance rate will be 100% at a monthly rate.
Project Manager will monitor training and watch over competencies for patient services staff,
admission staff, medical records staff, providers, nurses and licensed staff.
Standardized forms will be reviewed by the Compliance Committee annually. Compliance rate
will be no less than 95% for each year. Project Manager will conduct.
Patient surveys will be mailed 3 days after surgical discharge. Quantitative Questions will be
asked in regards to the use of white boards for visual communication and overall patient
satisfaction of communication. Compliance rate will be no less than 98% for each year.
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Patient/Guardian education program for abduction prevention
Video Surveillance system in all hallways, doorways, and nurses stations
Pediatric patients will be monitored while in a bassinet or pediatric bed/crib until the arrival of
designated guardian/custodial care into the treatment or authorized area.
Person(s) Responsible for Implementation:
Security Department Supervisor and Security Personnel
Patient Education Services Liaison
Director of Nurses
Admitting Staff and Supervisor
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from guardian occurs. Sample size will be randomly chosen by Compliance Committee. This
audit must be at 90% compliance rate.
All risk reduction measurement strategies will be evaluated and reported to Senior
Leadership within 3 months of completed and approved RCA and updated quarterly.
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