Nightingale Community Hospital: Sentinel Event

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Western Governors University
Joint Commission Compliance Audit
Task 2
AFT2 Accreditation Audit
By Cricket Besse 055895

Nightingale Community Hospital
Sentinel Event
Registrar, registered child (3 year old patient), obtained insurance card and entered demographics. She was then taken to pre-op where the nurse told mother that once in the OR the surgery would take about 45 minutes and then she would go to recovery. The mother informed the pre-op nurse that once her daughter went into the O.R. she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number phone number with instructions to contact her if her daughter got out of surgery sooner than expected. The Pre-op nurse wrote her number down on her note pad that she carries around in her pocket. The daughter was taken into surgery by the O.R. nurse nothing was mentioned about the mothers’ phone number or contact instructions to the O.R. nurse. After surgery the daughter was taken to recovery where the recovery nurse took care of the patient until she was ready to go to the discharge ambulatory care. The recovery nurse paged the patients’ mother when she was coming out of anesthesia, but could not locate her. The recovery nurse kept her until ready to go to the ambulatory care for discharge. Security had called and said the father was at the main reception to come visit the daughter. The discharge nurse also tried to page mother, who still was not available. The patient was crying and wanted to go home. The discharge nurse let the father back to see the daughter. After 30 minutes had passed and mother was still not present, the father offered to take the patient, home with him. Since the patient called him daddy and was excited to see him, discharge nurse thought it was ok to send her home with her father. The discharge nurse had him sign all pertinent paperwork sent her home with him. The mother returned 2 ½ hours later and found that the daughter was discharged 30 minutes earlier. Mother was extremely distraught and security was called and a “Code Pink” (hospital-wide child abduction alert) was activated. Local law enforcement was also contacted by hospital security. When security officer interviewed mother, she shared with him that she and patients father were divorced and that she had full custody of daughter and her siblings. The Daughter was located within 30 minutes of her mother’s arrival by local law enforcement, in the care of her father. He had taken her to his home to await the arrival of the mother. If the Pre-Op nurse would have passed on the mother’s phone number where she could be reached and noted that she was on an errand with sibling, a lot of the events could have been avoided. Roles of Personnel Present Surgeon

Supervises the actions of the surgical team, orchestrating their responsibilities and generally responsible for the outcome of the surgery. Chief Nursing Officer Responsible for overseeing and coordinating an organizations’ nursing department and its daily operations. Works to align the nursing staff with the mission, values and vision of the organization. Pre-Op Nurse Bring patient back, Changes her into hospital gown, confirms hours with post-op nurse, confirms patient has a ride home (name and phone number in chart), Witnesses signing of the O.R. consent, and they have a basic understanding of what the surgeon is going to do. Mark side of surgery will be on, Starts their IV, check surgeons orders or per protocol, put on antibiotics, shave or prep area. Check all paperwork. Check to see if there is the surgeons’ history and physical within 30 days. Is there lab work or EKG’s (if needed)? Recovery Nurse Provides constant care to patients immediately following surgery; anywhere from 30 minutes to a few hours until patient is stable enough to be transported to a hospital room or...
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