Analysis Root Cause Analysis Sentinel Event

Root Cause Analysis: Review of a Sentinel Event
Western Governors University

Root Cause Analysis: Review of a Sentinel Event
Brief Description of the Event
A 13 year-old girl, Tina, was admitted for outpatient surgery on September 14. Tina was accompanied by her mother, who was informed by nursing personnel she would be in surgery approximately 45 minutes and then recovery for one hour. Tina’s mother informed nursing personnel that she would be leaving, but would provide her cell phone number to be notified if Tina was ready prior to the anticipated time. Tina’s surgery and recovery time did not last as long as expected and her mother was unaware she was ready to be dismissed from the hospital. In the mean time, Tina’s
Simply put, quality improvement is making things better. Quality improvement concentrates on procedural issues due to deficiencies and errors that are often the result failures in the organization. The FADE method is utilized to focus, analyze, develop, execute, and evaluate patient safety and quality improvement. Nightingale Community Hospital should implement this method for analysis, implementation and reviewing procedures within the organization and provide guidance in the root cause
The patient was released to her father when the mother was unable to be located. Analyze: Why was the mother not contacted? The nurse attempted to page the mother, but she could not be located. No other attempt to locate the mother was made. Why was the patient discharged to home with the father before the mother could be located? Housekeeping was on the unit waiting to clean the room for the next admission. How could this event have been prevented? Develop: The admission process will begin with identification of patient and parent or guardian, EMR follow-up questions will be triggered by the patient birthdate. The questions “With whom does the child primarily reside” and “with whom will the child be dismissed to home with?” These questions will required upon a birthdate that is less than 18 years of age. These questions and answers will be made available to healthcare personnel when applicable for pediatric patients via a highlighted alert on the electronic medical record. A sensor will be attached to the ID bracelet upon admission. Verification of identity must be provided prior to dismissal of the pediatric patient. Housekeeping will not be notified of pending admissions until the room is empty and the patient has been discharged. Execute: This procedure will be implemented 11/1/2013. IT personnel will be responsible for adding the questions to the electronic medical record and highlighting the