Root Cause Analysis Due to Sentinel Event

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Analysis of Sentinel Event: Child Abduction
Root Cause Analysis (RCA): Child Abduction
Please note the root cause analysis and recommended action plan show evidence of the key components of the RCA matrix for the specific event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event

Tina, a 13 year old teenager admitted for day surgery, was inappropriately released to her father when her mother was delayed in returning to pick-up and release the daughter from the hospital. The hospital staff had no awareness of the family situation until the mother came back to the hospital and discovered that her tardiness had allowed the father, against the mother’s wishes, to check Tina out of the hospital. The hospital staff, had attempted to contact the mother multiple times prior to the check-out or release. According to the call logs, six attempts to contact the mother were made by the post-op nurse in the 45 minutes the mother was delayed in arriving. According to the admitting paperwork the insurance for Tina’s day surgery was under the father’s name and policy. The hospital followed standard admitting and release procedures, but was surprised when Tina’s mother did not show or answer her phone. Tina’s father did not indicate suspicion or nervousness, he provided the proper documentation and verification of identity. The daughter confirmed that the gentleman was her father and it was obvious they were comfortable with each other. When Tina’s mother arrived, she was extremely distraught, the hospital contacted security immediately, and a “Code Pink” (hospital-wide child abduction alert) was activated. The Local law enforcement was also contacted by hospital security and provided the police with the fathers contact information and address. As the hospital 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. This is not standard information the hospital required at the time of admittance. Within a few minutes phone calls were made to Tina’s father and police were dispatched to the father’s home. Tina was picked-up by local law enforcement within 30 minutes of her mother’s arrival at the hospital. Tina was in no immediate danger, and was resting until their mother could come get her. There were numerous errors that lead to the incident and the CEO of Nightingale Memorial Hospital assured Tina’s mother that this incident would be analyzed and processes put into place to prevent this type of event from recurring. Who participated in the sentinel event root cause analysis? Nightingale Memorial Hospital has a rotational committee that consistently is represented by the following departments: * Board of Directors – usually Assistant to the Chief Operating Officer * General Services

* Lead from Department Effected – Oncology, Pediatrics, Maternity, etc. * Patient Services
* Admissions
* Nursing Staff

Those participating in the review are listed below:
* Assistant to the Chief Operating Officer
* General Services Vice President of Security
* General Manager Pediatrics Department
* Patient Services Department Administrator
* Director of Admissions
* Lead Nursing Staff – Pediatrics / Maternity

Specific Task and Assignment of Sentinel Review Committee
The purpose of the review committee is to evaluate the parental abduction sentinel event which occurred on September 14. Provide and accurate investigation as to the base reason(s) of how and why the abduction occurred or was allowed, and provide recommended action items and 30 day monitoring to establish and recommend a policy or system improvement to prevent an event of this nature from occurring again in the future.

When deficiencies are noted, hospital leadership should establish task forces, made up of...
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