Sentinel Event Analysis

Running head: NIGHTINGALE COMMUNITY HOSPITAL SENTINEL EVENT

Sentinel Event: Child Abduction
Nightingale Community Hospital
Greer Elizabeth Unruh
Western Governors University

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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,
He is dumbfounded that this sort of situation could happen to one of his patients and blatantly blames the nurses. He questions their intelligence, asking how they did not know that the girl’s parents are divorced and only the mother has custody. The father is not allowed to take his daughter due to legal rights, and big legal issues are involved with inattentive behavior. Dr. Munoz is the number one ENT for outpatient surgeries at Nightingale and is afraid that with his neck on the line for this casualty, he will lose credibility. Surgeons are responsible for the medical operation itself, as well as making sure the patient gets from pre-operative care to surgery to post-operative care safely. In these regards, Dr. Munoz did his job, but is still unhappy with the negligence of the nursing staff. His office notes state who the custodial parent is, but the staff did not ask for his notes. One way of avoiding this mess and covering his tracks would be to make certain that all notes taken by all medical personnel are transferred onto the patient’s record so there is no
The obvious problem is lack of communication, which was pointed out by nearly every employee involved in the sentinel event. The most effective way of making sure this does not happen is to create a risk management plan that begins the minute the patient walks in the door. NCH should create a protocol where the registrar takes down all information, including anything regarding custody of the child and who is allowed to pick up the underage patient. A code can then be administered to each family and wristbands can be printed with that code, and if the person picking up the child at discharge does not have the same bracelet, then he or she is to remain in custody of the discharge nurse until the legal guardian of the child (or any adults that were predetermined by the dominant guardian to facilitate the pickup)