Communication Root Cause and Improving Patient Care

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Communication Root Cause and Improving Patient Care

By | Feb. 2011
Page 1 of 8
Case
On September 14, 2011, a 4 -year old minor was discharged from the ambulatory surgery post-op to the non-custodial parent. The child was admitted for treatment by the custodial mother during the pre-op work up the mother mentioned to the pre-op nurse that she had to leave to the hospital to run an errand with her 7-year old child. Nurse asked for the mother’s contact information and the mother instructed the nurse to contact if she had not returned to the hospital before the surgery was completed.

After the surgery was finished, the recovery nurse moved the patient to the recovery room and paged the mom over the hospital’s paging system. The recovery nurse explained he did not receive a response to the page. Once the patient was stable the recovery nurse transferred the minor to the discharge nurse, at which time the mother still had not arrived. The minor became upset and began to ask for her mother. The discharge nurse received a call from the recovery nurse informing her that the father was in the main reception area. The recovery nurse let the dad come back to comfort the child. Since mom had not arrived after 30 minutes the father agreed to take the child home. Discharge instructions were given and the father and child left the hospital. Shortly after the mom arrives upset and had explained to the discharge nurse that she was in the process of a divorce and had full custody of the child.

At 9am security were notified by ambulatory surgery of child abduction. The nurse was interviewed by security and stated the child had been missing for 25 minutes. Security contacted local authorities. Fortunately the child was found at the father’s home at 12:30pm. The father explained he had taken the child home since the mother’s whereabouts were unknown.

Root causes identified:
Security equipment factors such as security equipment not being available for outpatient areas. Staff-related factors such as insufficient orientation/training and insufficient...

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