Sentinal Event
Sentinel Event
Child and mother arrived at the hospital at approximately 5:00 a.m. to register for outpatient myringotomy surgery. Mother registered 3 year old child and was escorted to pre-op surgery area for further processing. Mother signed consents; child was gowned and assessed for surgery, i.v. and pre-op medication given. Mother informed pre-op nurse that she would be leaving while child was in the OR and would be returning once child was out of recovery. Pre-op nurse gave the mother an estimated time of 1 hour and 45 minutes for surgery and recovery time. Mother gave the nurse her cell phone number with instructions to call her if child got out of surgery earlier. Pre-op nurse recorded phone numbers and instructions in her personal notebook.
Child taken to OR at approximately 5:45 and was sent to recovery at approximately 6:30. Unclear if OR nurse tried to contact mother when child came out of surgery, also unclear if surgeon tried to contact mother about surgery outcomes. Child was in recovery for approximately 1 hour. Recovery nurse paged mother with no response. Recovery nurse also went to waiting room looking for mother. Recovery nurse did not retrace child’s path for further information.
Child moved to the discharge nurse at approximately 7:30 a.m. Mother paged with no response. Discharge nurse did not retrace child’s path for further information. Security called discharge area to ask if child’s father could come back. Discharge nurse said yes and noted that the child was very happy and relieved to see father. Discharge nurse waited until 8:00 before releasing child into fathers care. Unclear if this discharge was recorded in patients chart.
Mother arrived at 8:35 and was informed that the child had been released. Discharge nurse was not able to give accounting of where or with whom the child had been released and security was called at 9:00 and the hospital was put on a ‘code pink’. Local law enforcement was also notified.
Child and mother arrived at the hospital at approximately 5:00 a.m. to register for outpatient myringotomy surgery. Mother registered 3 year old child and was escorted to pre-op surgery area for further processing. Mother signed consents; child was gowned and assessed for surgery, i.v. and pre-op medication given. Mother informed pre-op nurse that she would be leaving while child was in the OR and would be returning once child was out of recovery. Pre-op nurse gave the mother an estimated time of 1 hour and 45 minutes for surgery and recovery time. Mother gave the nurse her cell phone number with instructions to call her if child got out of surgery earlier. Pre-op nurse recorded phone numbers and instructions in her personal notebook.
Child taken to OR at approximately 5:45 and was sent to recovery at approximately 6:30. Unclear if OR nurse tried to contact mother when child came out of surgery, also unclear if surgeon tried to contact mother about surgery outcomes. Child was in recovery for approximately 1 hour. Recovery nurse paged mother with no response. Recovery nurse also went to waiting room looking for mother. Recovery nurse did not retrace child’s path for further information.
Child moved to the discharge nurse at approximately 7:30 a.m. Mother paged with no response. Discharge nurse did not retrace child’s path for further information. Security called discharge area to ask if child’s father could come back. Discharge nurse said yes and noted that the child was very happy and relieved to see father. Discharge nurse waited until 8:00 before releasing child into fathers care. Unclear if this discharge was recorded in patients chart.
Mother arrived at 8:35 and was informed that the child had been released. Discharge nurse was not able to give accounting of where or with whom the child had been released and security was called at 9:00 and the hospital was put on a ‘code pink’. Local law enforcement was also notified.