Root Cause Analysis

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Accreditation Audit
AFT2: RAFT – Task 2

The purpose of this second task is to provide a logical description of a sentinel event which occurred at Nightingale Community Hospital and analyze all aspects of the event. This analysis includes a review of the personnel present, barriers to the personnel being able to adequately complete their job, and how future staff interactions may be improved.
In addition, the analysis will review the selected quality improvement approach to be used during the completion of a root cause analysis of the event and what can be done by Nightingale Community Hospital to ensure the sentinel event does not occur again.

A1 – Sentinel Event –
The following is a review by the Nightingale Community Hospital Quality Management (QM) Department of the Pediatric Patient Abduction Sentinel Event Reports provided by the staff with involvement in the event.
Description of the Event - Patient Tina, age 3, was at Nightingale Community Hospital on Thursday, September 14, 2013 for ambulatory surgery. At approximately 10:00 a.m. on the same day, Tina was taken into the Operating Room (OR). While Tina was in surgery, her mother left the hospital to run a quick school errand with her son leaving her cell phone number with the pre-op nurse.
Following Tina’s surgery, the Recovery Room Nurse paged her mother using the hospital-wide overhead paging system. Tina’s mother did not respond to the page. While in recovery, Tina became very distraught. She was crying and voicing to the Discharge Nurse that she wanted to go home. At this time, the Discharge Nurse was informed that Tina’s father was at the hospital to see her. The Discharge Nurse stated that when Tina saw her father she was relieved, called him Daddy, and said she was ready to go home. After waiting an additional 30 minutes for Tina’s mother to return, the Discharge Nurse released Tina to her father.
When the mother returned to the hospital at 12:30 p.m., she discovered

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