RCA (ROOT CAUSE ANALYSIS)
FOR THE SENTINEL EVENT REPORT
HAPPENED ON MAY 14,
THURSDAY AT 9:00 AM.
1. SENTINEL EVENT DESCRIPTION.
The pre-op nurse told the mother that once Tina (The patient), a 3 years old child, went to the OR, her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour. The mother told the nurse that once Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number with instructions to contact her if Tina got out of surgery sooner than expected.
Tina’s mother returned to pick her approximately 2 ½ hours later and found that Tina was discharged 30 minutes earlier.
Tina’s mother was extremely distraught, security was called, and a “Code Pink” (hospital-wide child abduction alert) was activated. Local law enforcement was also contacted by hospital security. When the security officer interviewed the mother, she shared with him that she and Tina’s father were divorced and that she had full custody of Tina and her siblings.
Tina was located within 30 minutes of her mother’s arrival, by local law enforcement, in the care of her father. He had taken her to his home to await the arrival of the mother. No charges were filed against the father.
2. PERSONNEL ROLES PRESENT DURING THE SENTINEL EVENT.
1. PREP-OP NURSE.
Prepared patient for surgery, brought the mother and daughter (Patient) to the prep-operative area, completed the prep-operative nursing assessment, changed the patient to a hospital gown, started the patient IV, administered the prep-op medications, documented in the administration medication record, asked the mother to sign the consent form for surgery, took the mother's name and cell phone number, the mother mentioned that she will be gone during the surgery for a while, and to please give her a call when the surgery was done, but that she should be back by the time the surgery should be done. She didn't ask for legal custody or guardianship, because it isn't one of the questions in the nursing assessment form.
Later on, she took the patient back to OR and handed the patient to the OR nurse, but she never passed any information to the OR nurse about the mother leaving for a while, during the surgery, also no contact about the mother was ever passed.
2. OR NURSE.
Received the patient from the prep-op nurse, without receiving any information about the situation with the mother leaving while the daughter will be in surgery, no names and phone numbers weren't also given.
3. RECOVERY NURSE.
After the patient come out of surgery, the OR nurse brought the patient to him, the OR nurse gave him the report about the patient's surgery, provided patient with post-anesthesia care till the patient was ready to go to the ambulatory surgical unit, post-operative area to prepare the patient for discharge.
When the patient woke up, he paged the mother in the waiting area, and the mother never responded, he stayed with the patient till was time to take the patient to the discharge nurse.
4. DISCHARGE NURSE.
She received the patient from the recovery nurse, because the patient was ready to go home, the recovery nurse mentioned to her that he paged the mother, but she didn't respond and she didn't show up, at that time the discharge nurse didn't know what to do. Then, she received a call from the security officer, telling her that the patient's father was at the waiting area, she allowed the father to come to the discharge area and see his daughter, she hear when the patient called him daddy and she felt better to know that a family member was at the hospital, she waited for another 30 minutes and the mother...
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