The sentinel event that occurred at Nightingale Hospital involved a missing minor child, named Tina. Tina was brought to the hospital for outpatient surgery by her mother. Tina’s mother remained with her child until time for surgery, at which time the pre-op nurse told the mother that the surgery would take about 45 minutes, then the patient will go to recovery. Tina’s mother told the pre-op nurse that while Tina was in surgery she was going to run errand and should be back in about an hour. The mother gave the pre-op nurse cell phone number and to call if Tina got done earlier than expected. Tina’s mother returned to the hospital 2 ½ hours later, and Tina has already been discharged. Security was notified and a code pink was initiated. PERSONNEL:
Registration; enters information regarding patient such as name, address, phone number, as well as insurance information. Pre-op Nurse: receives patient from waiting room, has patient change into a gown, take vital signs, give medications if ordered, assesses patient, explains procedure to mother and child, answers any questions and get consents signed. Also obtain contact information for the mother. OR Nurse: received patient from pre-op and remains with patient thru out her procedure. Surgeon is with the patient and performing the procedure.
Recovery Nurse receives patient from OR and monitors patient until alert or criteria met to be transferred for discharge home. Discharge Nurse: discharged patient home with father after not being able to locate the mother. Security is notified of missing child upon mothers return.
Chief Nursing Officer (CNO) notified to investigate where the breakdown occurred. Father of child: the patient was discharged to father without mothers consent or knowledge Local police: notified when child was reported missing to aid in the investigation. Charge nurse: charge nurse should be informed if the minor child’s parent was leaving the premises....
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