A.1: Description of the Sentinel Event
At about 12:30 PM on Thursday, September 14th, a sentinel event occurred that involved a potential child abduction. Tina, a 3 year old child, was scheduled for a routine, same-day surgery at Nightingale Community Hospital to have ear tubes put in both ears. Tina was brought to the hospital by her mother, who had recently been divorced from Tina’s biological father; Tina’s mother has full custody of the children, including Tina.
After Tina was registered and taken to the pre-op area of the hospital, the pre-op nurse informed Tina’s mother that the actual surgery would take approximately 45 minutes, and then Tina would need to stay in recovery for at ...view middle of the document...
Thirty minutes later there was still not a response from the mother. The father offered to take Tina to his home until they could get a hold of the mother and make arrangements for the mother to pick up Tina at the father’s house.
Tina’s mother returned 2 ½ hours after leaving the facility and found that Tina was discharged 30 minutes earlier. Hospital staff was unaware that the father had taken Tina to his house. Upon finding out that Tina was missing, Tina’s mother was extremely distraught, and feared the worst about her daughter.
Hospital security was notified, and a hospital-wide child abduction alert (Code Pink) was initiated. Hospital security also reported the situation to local law enforcement. During the interview with hospital security, the mother informed them that she and Tina’s father were recently divorced. Within 30 minutes of the mother arriving at the hospital, Tina was located by law enforcement at her father’s house. Tina was being well taken care of by the father, and no charges were filed against him.
A.2: Roles and Responsibilities of the People Involved in the Event
Eight hospital employees interacted with Tina, and are therefore involved in the sentinel event. Tina’s father and mother were also part of the event. This report will analyze the role and involvement of each of these people and the part they played in the event. Their connection to the event will be addressed in order of their interaction with Tina and her parents.
Responsibilities include registering the patient, entering the demographics and insurance information into the EMR (Electronic Medical Record), make a copy of the insurance card, and have all necessary documentation signed, including the authorization to treat and assignment of benefits form.
Katie Jessop, the Registrar, entered all the necessary patient information into the medical record just as she had been trained to do, and according to current process standards.. Katie did not ask for other identification, and did not ask about custody information as it is not part of the approved process.
Responsible to bring the patient and family member back to the pre-op area, change the patient into a readily accessible hospital gown, complete the pre-op nursing assessment, start the patient’s IV, administer pre-op medications and document them on the patient record, and get the Informed Consent formed signed.
Greta Doppke, the pre-op nurse, called Tina and her mother back to the pre-op area where Tina was prepared for her surgery. Greta informed the mother that the surgery would take approximately 45 minutes, and that Tina would need to be in recovery for at least an hour afterwards. The mother informed Greta of an errand she would need to run, but that she would return in time to pick up Tina from recovery. The mother gave Greta her cell phone number, and asked to be informed if the surgery was completed earlier than expected. Greta wrote the mother’s...