RAFT Task 2 Article

Root Cause Analysis: Overview of a Sentinel Event

Traditional western Governors School

Root Cause Research: Review of a Sentinel Event

Brief Explanation of the Function

A 13 year-old girl, Tina, was admitted for outpatient medical procedures on Sept 14. Tina was combined with her mom, who was informed by nursing personnel she would be in surgical treatment approximately forty five minutes and then recovery for one hour. Tina's mom informed nursing jobs personnel that she would end up being leaving, nevertheless would provide her cell phone number to be notified in the event that Tina was ready before the anticipated time. Tina's surgical procedure and restoration time would not last as long as predicted and her mother was unaware she was willing to be dismissed from the medical center. In the mean time, Tina's father found see how the lady was doing. Prior to termination, hospital staff attempted to get in touch with Tina's mother via the phone six occasions in 45 minutes per call up logs, although were unable for making contact. Admitting paperwork and insurance data was examined with information showing the guarantor was Tina's dad. Nightingale Community Hospital adopted the standard acknowledging and discharge procedures for their facility. Tina's father would not seem nervous or suspicious and offered proper documents of identity. Furthermore, Tinaja confirmed that he was her father and did not seem to be upset or perhaps surprised to find out him. Tina was improperly discharged with her father against her mother's wishes, because of the hospital workers being unaware of the family situation. Tina's mother went back to the hospital after he was gone for 2 and one-half hours operating errands. At this point, she learned that Tina was discharged from your hospital with her daddy. Tina's mother became incredibly distraught and hospital security was approached immediately. Tina's mother informed hospital reliability that the lady was divorced from Tina's father and she had retained full custody of Tina and her bros. This type of data is not standard data required throughout the admitting procedure. A child kidnapping alert or " Code Pink” was initiated. Clinic security advised local police of the child abduction and provided the father's info and treat. Tina's daddy was contacted via mobile phone by regional law enforcement and in addition they proceeded to go to Tina's father's home to retrieve her. Tina is at local law enforcement officials custody inside 30 minutes of her single mother's arrival to the hospital, following resting in her dad's home awaiting her mother to pick her up. Staff Involved

This personnel took part in in the sentinel event about September 16; registrar, pre-op nurse, OR PERHAPS nurse, restoration nurse, post-op nurse, surgeon, chief nursing jobs officer, security and risikomanagement. The areas damaged during the sentinel event had been registration, surgical treatment, medical staff, security, plus the hospital status. Interviews were conducted with personnel recognized as being present and included during this sentinel event. The registrar verbalized she got initial exposure to the child and her mother. She explained she acquired the required insurance information, built a copy of the card and entered this information into the electric medical record. The suceder is initial point of contact intended for patients going into the hospital. The registrar will certainly obtain patient information, have the patient or perhaps guardian signal appropriate HIPAA documents, supply the patients bill of privileges and immediate the patient towards the correct area of the hospital or perhaps notify workers to meet the individual and escort them to the appropriate area. The pre-operative nurse has the responsibility of concluding an evaluation, verifying gives permission for surgical procedures are signed or acquiring the necessary consents, providing any educational demands, obtain contact information for the family in case of emergency, begin any pre-op IV's, and administer pre-op medications. The pre-op registered nurse verbalized your woman had finished the required pre-op...

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Patient safety—Quality improvement. DIMINISH method. Gathered from