Raft Task 2

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RAFT Task 2
Sharon Walb
Western Governor's University

RAFT Task 2
A.1Sentinel Event
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). Root Cause Analysis: Potential Child Abduction

Recently a three year old female was brought to Nightingale Hospital for an outpatient surgical procedure accompanied by her mother. They presented to the registrar who entered all information into the computer and copied insurance card, she did not obtain any parental photo identification or inquire about custody arrangements. Patient and her mother were taken to the pre-operative area to prepare for surgery and complete the necessary physical assessments, as well as sign consents for the procedure. The nurse documented the contact information for the mother to be reached after the procedure because she would be leaving the facility to attend to another child; this was documented on the nurse’s notebook. The patient was taken to the operating room and subsequently the recovery room. The recovery room nurse called out to the waiting room but the patient’s mother was not there. Upon completion of the recovery time and patient more awake, she was transferred to the post recovery area to await discharge. Mother was still not present and patient becoming more anxious and crying, male presented to unit and stated he was the father, patient called him “daddy” and appeared to be comforted by his presence. The patient was cleared for discharge and the post-operative nurse discharged the patient with her father after reviewing instructions. Approximately 2 ½ hours later the mother presented to the unit and was informed that the patient had been discharged to home with her father. Mother very upset, security notified and “code pink” announced overhead, local law enforcement were also notified. Mother shared that she and the patient’s father are divorced and that she has sole custody of the children. Patient was located at her father’s residence. Participants:

The following team members participated in the root cause analysis; registrar, pre-op nurse, OR nurse, recovery nurse, post-op nurse, surgeon, chief nursing officer, security and risk management. When did the event occur: September 29, 2012

The following areas were impacted by this event: registration, surgery, medical staff, security and the hospital reputation. This flow chart will show how the process currently works:

The human performance factors that have contributed to this error include a lack of clearly defined policy on custody inquiry, process for identifying parent and child as a couplet, communication both for information that is available such as the mothers contact information and for handoffs, physician office information to shared with the hospital, delay in reporting missing child or perhaps the concept that staff did not even realize it was a problem. There were no equipment issues with the current process in place. The organization does have a few controllable factors and the ability to develop and implement policies to safeguard the youngest of our customers, improve communication through the development of handoff tools, implement a banding system for parents and children and require that any pediatric patient in-house must have a responsible adult able to give consent on their behalf, available in house at all times during their stay. The uncontrollable external factors that was present was the father coming to see his daughter, although this is not able to be controlled by the hospital it is able to be influenced by allowing the family to “opt out” and not sharing that the child is a patient. There is a potential for reoccurrence in several areas of the organization including; radiology, the emergency department, pediatrics, obstetrics, lab, physician practices...
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