Raft2 Sentinel Event

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Sentinel Event: Child Abduction
Description of Event
A three-year-old patient presented to the hospital for outpatient surgery of bilateral myringotomies with mother. After the patient was registered, consent for surgery signed by mother, and prepped for surgery, the mother gave the pre-op nurse her phone number and left to run an errand with instructions to be called if her daughter was finished with surgery sooner than expected. The mother was expecting the patient would be ready to go home in about 2 hours. The pre-op nurse stated that she wrote down the mother’s phone number in her own notepad to call her. The patient completed surgery and was taken to recovery. At this time the recovery nurse paged out to the waiting room for the mother as parents are encouraged to come back to the recovery area as the children come out of anesthesia. With no answer from the page and the patient awake and stable, the patient was then given to the post op nurse for discharge. The post op nurse stated that the recovery nurse had tried to page the mother, but made no mention of trying herself. The patient was becoming upset because she had not yet seen her mother. The security personnel called informing the nurse that the patient’s father had arrived and the patient happily met the “father,” so the discharge nurse waited another thirty minutes before releasing the patient to the father as there was no sign of the mother. When the mother of the patient arrived thirty minutes after the patient had been discharged looking for the patient, security was called, an internal code pink was initiated and law enforcement notified. Security stated that the mother informed them she had full custody of the patient and that the parents were divorced. The patient was found within thirty minutes in the care of the patient’s father at home. No charges were filed against the father. Roles of Personnel

Registrar: A hospital registrar “performs scheduling, registration, verification and reception for all outpatient surgical patients (Northeast Health, 2012).” A hospital registrar is very important to hospitals, as they are the people who obtain insurance and billing information so that the hospital can get paid for the services it provides. The registrar at Nightingale Hospital stated that she entered the patient’s demographics and insurance information, obtained consent to treat the patient, and copied the patients insurance card. She did identify that, as it is not standard process, she did not ask for any other form of identification from the patient’s mother or ask about custody. At most hospitals that deal with pediatric patients, a standard part of the registration process is to have the parent’s present identification and a social security card of the patient. This is one way to help identify the parents as the parents of the patient. While custody information does not have to be given, as part of the consent for treatment there is a clause stating that the parents who bring the child in are the only people to whom the child will be released upon discharge. Usually an identifier is placed on the parents by registration, such as a matching wristband that has the patient information and says parent, which helps staff know who to release the patient too. As there is no such process in place at Nightingale Hospital to verify parent identification, the registrar completed her job and moved on to the next patient. Pre-Op Nurse: The pre-op nurse is responsible for getting the patient ready for surgery. From “assess patient’s status, to reviewing the chart, identifying the patient, verifying the surgical site and marks site per institutional policy, establishing IV line, giving medications, and providing emotional support (Nurselabs, 2012).” The pre-op nurse stated in her interview that she was very busy the day of the patient’s surgery and did her usual assessments and patient preparation, however she did have to run around to track down a gown. The...
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