On Thursday September 14th at around 12:30 pm the hospital had a sentinel event which involved a missing child. The event details are as follows: Tina was scheduled for same day surgery and was brought to the hospital by her Mother. Her Mother was informed that the surgery would take approximately 45 minutes and that Tina would be in recovery at least 1 hour. Tina’s Mother informed the pre-op nurse that she had an errand to run involving Tina’s older sibling. Tina’s mother left the pre-op nurse her cell phone number with instructions to call her if Tina got out of surgery and was ready to go before she returned. Prior to Tina’s mother returning Tina’s father showed up to check on her, and finding that she was ready to go he took her to his house until the mother could pick her up. When Tina’s mother returned 2 ½ hours later she found Tina missing and the staff did not know that her father took her. The hospital activated a Code Pink and notified the local police department. When the hospital security interview the mother they learned the parents were divorced and that she had full custody of Tina and her other siblings. The local police found Tina at her father’s home within 30 minutes of Tina’s mother returning to the hospital. No charges were filed against the father.
There were eight main employees that interactive with Tina, her mother and father in the sentinel event. We will be looking at each of their roles in the order that Tina and her parents interacted with them:
Katie Jessup is the registrar that admitted Tina to the hospital. She asked the standard questions, made copies of the insurance information and recorded it all into the computer system for admission and billing. As she was trained she did not ask any questions that were not on the standard questionnaire form that all patients fill out.
Greta Doppke is the pre-op nurse who took Tina and her mother back to prepare for her surgery. Greta completed her nursing pre-op nursing assessment, started her IV, administrated her pre-op surgery medications and documented it all on the administration documentation records. Greta had Tina’s mother sign the consent form for the surgery and made a note in her note book of the mothers name and cell phone number because she wanted to be notified when Tina came out of surgery. Greta then took Tina over to the surgical suit and handed her of to Rosemary Fry the O.R. Nurse.
Rosemary Fry is the O.R. Nurse that received the patient from Greta. She took Tina into surgery and had no interaction with Tina’s mother, was not informed about calling her after the surgery and worked with Dr. Munoz for the procedure.
Dr. Carlos Munoz was the surgeon on this case. He claims that in his patient notes that he states how the custodial parent. He also claims that the Hospital staff never request his patient notes.
Jon Peters is the recovery room nurse, he took report from Rosemary. He over saw Tina’s post recovery. When Tina was ready to be discharged he called out to the waiting room and also paged Tina’s mother. When she did not respond He Tina to Kim the discharge nurse
Kim Johnson is the discharge nurse that took Tina and report from Jon Peters. Jon notified Kim that he was unable to find Tina’s mother. Tina started to cry and be very un- happy. Kim found out that Tina’s father was at the front desk so Kim invited him back. Tina recognized him and called him father so Kim knew that he was Tina’s father. After they had been waiting for 30 minutes Tina’s father suggested that he could take Tina to his home until the mother could come and get her. Kim agreed that that would be a good idea and had him sign Tina out and sent her home with him.
Tim Blakely was the security guard that was called when Tina was found missing. Tim was notified 25 minutes after Tina was missing. Tim went to the discharge area and interviewed the nursing staff.
Anna Lin-Dilarina is the Chief...
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