Sentinel Event

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A1. Sentinel Event

Review of the medical record for the specified patient (SP) was completed 09/16/12. The medical record revealed that the SP was a minor child with a diagnosis of history of frequent and recurrent tonsillitis and was scheduled to have the tonsils and adenoids removed 09/14/12 at 10:30 AM as an outpatient procedure. Review of the medical record for the day of 09/14/12 revealed that the SP was admitted to the pre-admission testing area at 9:00 AM. At 10:00 AM the SP was in the pre-operative area with the peripheral intravenous line in place and the pre-operative medications were being administered. At 10:30 AM the SP was in the operating room (OR) and the procedure was performed as scheduled. At 11:15 AM, the SP was moved from the OR to the post anesthesia care unit (PACU). At 12:15 PM, the SP was successfully recovered from the procedure and both the surgeon and the anesthesiologist cleared the SP to go home. The medical record revealed a nurse’s note by the pre-operative nurse on 09/14/12 at 10:30 AM that documented a conversation between the pre-operative nurse and the SP’s mother where the mother stated she was leaving to run an errand involving an older sibling and left a cellular telephone number. The only documented instruction from the mother was for the nurse to call if the SP got out of surgery sooner than expected. In an interview with the PACU nurse conducted on 09/15/12 at 10:00 AM, the PACU nurse stated that on 09/14/12 at approximately 12:30 PM, the patient was released for home to her father, who was identified by his driver’s license; the PACU nurse stated that she provided written instructions for the patient’s post-operative care and follow up appointment to the father. The PACU nurse stated that the patient’s father verbalized understanding of the discharge instructions and left with the patient. The medical record lacked documentation of this encounter. The medical record also lacked documentation of any restrictions as to which parent was permitted to take the patient home. The patient’s mother arrived at the hospital on 09/14/12 at approximately 1:00 PM to take the patient home and was extremely distraught when she discovered her daughter was not in the PACU as she expected. There was a shift change at 1:00 PM and the oncoming nurses did not know that the patient was released to her father. As a result, security was called and a hospital-wide child abduction alert (code pink) was activated. In addition to hospital security, local law enforcement was also notified of the missing child. The SP’s mother told the hospital security officer that she and the SP’s father were divorced and she had full custody of the SP and the SP’s siblings. On 09/14/12 at approximately 1:30 PM, the SP was located at the father’s residence, in the care of the father. The SP’s father stated that he took the SP to his residence to wait for the SP’s mother to arrive. No charges were filed against the SP’s father. The hospital management and security personnel assured the SP’s mother that this incident would be investigated and processes would be put in place to prevent it from happening in the future.

A2. Personnel

There were several employees who had interactions with the SP and her mother during the outpatient hospital procedure. The first person was the hospital registrar who took the SP’s demographic information from the SP’s mother. The next person was the pre-operative nurse who took obtained the SP’s clinical information and medical history from the SP’s mother, performed the initial physical assessment (height, weight, vital signs, cardio-pulmonary, and head to toe), and obtained peripheral intravenous access. The people who then interacted with the SP were the surgeon, the anesthesiologist, and the operating room nurses. The surgeon also had an office visit with the SP and her mother in the days leading up to the surgery. The OR nurse took over care when the SP was...
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