Sentinel Event: Child Abduction
Nightingale Community Hospital
Greer Elizabeth Unruh
Western Governors University
Communication is the be all and end all in a successful corporation. Nightingale Community Hospital was unfortunately lacking in this department when Tina, a child who was about to be discharged, was thought to have been abducted from the vicinity. The personnel in charge of Tina’s wellbeing at that time all gave their opinion of what happened and what preventative measures could have been taken.
Tim Blakely, security officer, is in charge of securing the premises of the building and ensuring that all patients are protected from outside harm. At 9:00 AM, Tim received a page regarding a potential abduction of a small girl. He immediately made his way to the ambulatory discharge center to speak to the nurse that was supposed to be watching the girl. The nurse had known that Tina was missing for at least 25 minutes, and Tim was frustrated that he had not been alerted as soon as possible. He made a mental note to prepare a hospital wide memo clarifying that there is to be no delay whatsoever if a child is reported missing from the facility. Confusion blooms from inconsistency of rules; if the policies regarding child abduction are not uniform, there is no smooth way of responding appropriately and immediately. Tim believes that child abduction drills would benefit the hospital employees. Strict rules should be enforced in order to guarantee patient safety, such as delegating wrist bands to every person admitted to the hospital and checking every wrist band at the time of discharge. Security guards are hired to protect, and it would be easier to do so with the compliance of all other hospital personnel.
The registrar, Katie Jessup, entered Tina’s information into the registration database when she and her mother checked in. It is not part of the process to ask the patient and guardian for additional identification or ask for elucidation concerning custody of the child. Katie did not have a lot to say except for that she believes it to be the nurse’s responsibility to make sure that the patient goes home with the correct parent or guardian. The duties of the registrar are to acquire all necessary medical and personal information and create a chart that will follow the patient to every area of the hospital he or she will end up at. This chart ensures that the patient receives the right types of medication, highlights any adverse effects to drugs, and lists all potential warnings and previous ailments so that all doctors that come in contact with the patient are on the same page. 3
The Chief Nursing Officer is the individual who resumes all responsibility for the actions of all nurses in the hospital. Anna Liu-Dilarno, Chief Nursing Officer at NCH, was not physically present for the sentinel event, and although she was not involved, carries the burden of the event because of her high position. She admits to there being some problems in communication between nurses, mostly concerning information that is overlooked and consequently is not entered into the patient’s file. Anna wants to do all she can to ensure the best nursing care, and to do that she must make sure that the flow of information is done properly and without a hitch.
The OR nurse, Rosemary Fry, believes that each department is looking after their own interests in this case and nobody wants to take the blame. She says that there needs to be better communication between departments, which is the obvious conclusion, and states that this is a recurring problem that affects the hospital in other ways. Rosemary is responsible in seeing that pediatric patients are taken care of in the operating room during surgery and then transfers the patient to post-operative care, which is exactly what she did.
Carlos Munoz, a surgeon at NCH, sounded very upset and enraged in his...