Sentinal Event

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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. Security and police were able to determine that the child had been released to the father and the child was located shortly after at the fathers’ home. Personnel Involved-assumed duties and actual duties

Registrar-Katie Jessup registered Tina as required by existing hospital policies. She communicated to the pre-operative nurse when child was registered. Her actual duties also include entering, updating and verifying all data necessary for the patient and third-party payers, and gathering signatures for all required forms Pre-operative Nurse-Gretta Doppke recorded and preformed all usual pre-operative requirements. Gretta recorded the assessments data, gowned the patient and started her IV and administered pre-operative medication. She also obtained the signed consent forms for the surgery. Mother stated that she would be leaving the hospital for a personal errand and requested that she be called when child is out of surgery. Nurse recorded request and contact information in personal notebook. Pre-operative nursing primary responsibilities are to provide information and emotional support for patients and their family members and ensure that all preoperative data have been accumulated and to maintain patients baseline hemodynamic statuses (PubMed. 1997). OR Nurse-Rosemary Fry took child from Pre-operative area to surgery. She worked with Dr. Munoz in the actual surgery. When surgery was completed she monitored child until stable and moved her to recovery. Actual duties also include a review of the preoperative assessments and to assist with patient education for the upcoming surgery. This position requires high-quality interaction with physicians, technicians and other nursing staff to provide high-quality care and to ensure patient safety ( 2013). Recovery Nurse-Jon Peters received a stable child and surgery report from OR. He assisted the child to wake from anesthesia, tried to contact the mother by paging and going to the waiting...
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