Raft2 Sentinel Event

Sentinel Event: Child Abduction Description of Event A three-year-old patient presented to the hospital for outpatient surgery of bilateral myringotomies with mother. After the patient was registered, consent for surgery signed by mother, and prepped for surgery, the mother gave the pre-op nurse her phone number and left to run an errand with instructions to be called if her daughter was finished with surgery sooner than expected. The mother was expecting the patient would be ready to go home in about 2 hours.

The pre-op nurse stated that she wrote down the mother’s phone number in her own notepad to call her. The patient completed surgery and was taken to recovery. At this time the recovery nurse paged out to the waiting room for the mother as parents are encouraged to come back to the recovery area as the children come out of anesthesia. With no answer from the page and the patient awake and stable, the patient was then given to the post op nurse for discharge. The post op nurse stated that the recovery nurse had tried to page the mother, but made no mention of trying herself.

The patient was becoming upset because she had not yet seen her mother. The security personnel called informing the nurse that the patient’s father had arrived and the patient happily met the “father,” so the discharge nurse waited another thirty minutes before releasing the patient to the father as there was no sign of the mother. When the mother of the patient arrived thirty minutes after the patient had been discharged looking for the patient, security was called, an internal code pink was initiated and law enforcement notified.

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Security stated that the mother informed them she had full custody of the patient and that the parents were divorced. The patient was found within thirty minutes in the care of the patient’s father at home. No charges were filed against the father. Roles of Personnel Registrar: A hospital registrar “performs scheduling, registration, verification and reception for all outpatient surgical patients (Northeast Health, 2012). ” A hospital registrar is very important to hospitals, as they are the people who obtain insurance and billing information so that the hospital can get paid for the services it provides.

The registrar at Nightingale Hospital stated that she entered the patient’s demographics and insurance information, obtained consent to treat the patient, and copied the patients insurance card. She did identify that, as it is not standard process, she did not ask for any other form of identification from the patient’s mother or ask about custody. At most hospitals that deal with pediatric patients, a standard part of the registration process is to have the parent’s present identification and a social security card of the patient. This is one way to help identify the parents as the parents of the patient.

While custody information does not have to be given, as part of the consent for treatment there is a clause stating that the parents who bring the child in are the only people to whom the child will be released upon discharge. Usually an identifier is placed on the parents by registration, such as a matching wristband that has the patient information and says parent, which helps staff know who to release the patient too. As there is no such process in place at Nightingale Hospital to verify parent identification, the registrar completed her job and moved on to the next patient.

Pre-Op Nurse: The pre-op nurse is responsible for getting the patient ready for surgery. From “assess patient’s status, to reviewing the chart, identifying the patient, verifying the surgical site and marks site per institutional policy, establishing IV line, giving medications, and providing emotional support (Nurselabs, 2012). ” The pre-op nurse stated in her interview that she was very busy the day of the patient’s surgery and did her usual assessments and patient preparation, however she did have to run around to track down a gown.

The nurse also stated that she wrote the mother’s phone number down on a notepad that she carries with her at all times. The mother requested to be called when the surgery was complete. The nurse made no mention of passing the phone number off to any of the other nurses or making a note on the chart for the other nurses to see regarding the mothers wish to be called and the number she could be reached at. The nurse also stated that she did not ask for custody information and felt that the doctor’s office should be responsible to get and give that information to the hospital.

Overall the nurse did her basic work to prepare the patient for surgery. OR Nurse: The next nurse to receive the patient and have contact with her was the OR nurse. This nurse “maintains aseptic technique, controls the environment of the OR suite, transfers patient to operating room bed or table and positions the patient: function alignment, exposure of surgical site, applies grounding device to patient, ensures that the sponge, needle, and instrument counts are correct and completes intraoperative documentation (Nurselabs, 2012). The OR nurse expressed concern in her interview that there was a possibility of this type of incident happening in other areas or departments in the facility as the OR is not the only area that separates children and parents to do procedures or tests. Overall the nurse did not identify much of her role and interactions with the patient or other staff in her interview. It is therefore assumed she did her role as described above but nothing further. Recovery Nurse: After the OR the patient was then sent to the recovery nurse.

His role is to “determine the patient’s immediate response to surgical intervention, monitor patient’s physiologic status, assess and reassess patient’s pain level and administers appropriate pain relief measures, maintains patient’s safety (airway, circulation, prevention of injury), and assess readiness to be discharged or admitted (Nurselabs, 2012). ” The recovery nurse stated that he received report from the OR nurse and took care of the patient as described above. As the patient woke up he “paged” to the waiting area to have the mom brought back.

She did not answer and as the patient was stable and awake he took her to the post op nurse. There was no mention of the recovery nurse calling the mother as she had expressed to the pre-op nurse. The recovery nurse did not appear to know of these wishes, have her phone number, or be aware that the mother was not going to be in waiting room. The lack of communication from one staff member to another becomes apparent at this point in the patient’s care. The recovery nurse did not have any ideas on how to improve the system, but did express concern over lengthy and formal hand off report among nurses.

The recovery nurse did not think outside of the normal standard when it came to trying to contact the patient’s mother, however he did his job according to hospital standards. Post-Op Nurse: The last phase of the patient’s care was to be transferred to the Post-Op nurse for “continued monitoring of patient’s physical and psychological response to surgical intervention, provides teaching to patient and family for discharge (Nurselabs, 2012). ” The nurse stated that she was informed that the recovery nurse could not reach the mother via page.

There is no mention of her trying to obtain a phone number to reach the mother. The nurse expressed that the patient was very distraught over not having her mother there. When security notified her that a person who stated he was the father was there, the nurse agreed to let him in and the patient was very happy to see him. The nurse stated in her interview that she waited for the mother, but when she did not show agreed to discharge the patient to the father’s care. The nurse did not check any identification from the father that acknowledged he was in fact the patient’s father.

While the nurse did not have a specific hospital policy to follow regarding discharge of a patient, there was no extra effort on the part of the nurse to contact the mother per her report. Had there been notification on the patient chart regarding custody or a phone number the nurse could have easily verified information and not let the patient leave or gotten the mother’s approval for discharge. The nurse adequately took care of the patient during her time in the nurse’s care, however her choice to discharge the patient home without the mother was a lapse in judgment causing an error that could have potentially harmed the patient.

Security: A security officer at a hospital has many responsibilities and depending on the needs of the hospital those duties may vary. Overall the officer is supposed to “write daily reports regarding the activities and disturbances (if any) that occur during his serving period, checks lights, alarm system, windows, doors, and gates, gives access to family members to see their patients, responds to any fire alarms, violent patients, and assists with helicopter landings (Sandhyarani, Ningthoujam, 2011). The security officer at Nightingale Hospital was responsible for bringing the “father” of the patient to the post-op care area to meet the patient, as well as responding to the “code pink” and notifying law enforcement of the abduction. The officer expressed concern over the delay in time of reporting the abduction when in fact, the nurse was unaware that the mother did not know the child had been discharged. The officer had an idea for using the same alarm coded bands used in the OB department with any pediatric patient and placing sensors around the hospital.

It is great that he is thinking of new ways to help improve the system from a security standpoint. The officer responded to the situation quickly and efficiently using the information and resources he had available at the time. In the end the child was found and he therefore performed his duty quickly and efficiently. Surgeon: The surgeon’s responsibilities include ensuring that the patient is a good candidate for surgery, preparing the parents and patients for surgery, performing the surgery, overseeing the patients care post surgery. The urgeon who worked on the patient at Nightingale Hospital stated that he is the #1 ENT physician at the hospital. That implies he is very good at what he does. He stated that his office had records that state the mother is the primary custody holder of the patient and that the hospital did not get those records. While the hospital could have obtained the records, simply adding the question to the registration process would rectify the situation. The surgeon is very angry that this incident occurred and he does have a right as this is his patient and if these things continue to happen he will not have patients.

The surgeon role is the overseer of the patient’s care before, during and after surgery. The surgeon completed the surgery and care of the patient as part of his job. Chief Nursing Officer: This person is responsible for just about anything that happens in the hospital from a nursing standpoint. This means that anything that is going right or wrong they deal with. The officer usually sits on many different committees to help with improving and maintaining staff education, competence, patient safety, and hospital management.

The officer was not involved in the sentinel event, however it will be her responsibility to form committee, to complete the documentation, and to develop a way to ensure the event does not happen again. Barriers There are many different barriers that can impede effective interactions among people. These include physical, emotional, communication, language and cultural barriers (Ivanov, Tatyana, n. d). Physical barriers include demand of the nurse’s jobs including being short staffed, time constraints, technology, and unable to do face to face hand off reports. Emotional barriers include stereotyping, fear, anger, frustration, and mistrust.

Communication barriers can encompass all the types of barriers. This barrier inhibits people’s ability to speak so that others understand, not all the information is given, and an inability to fully listen to what is said. Language and Cultural barriers include not being able to understand someone due to an accent, different meanings of words when translated from one language to another, and not understanding or respecting cultural views or practices. In this situation all of the staff experienced some form of barrier during the course of the patients visit. The biggest barriers appear to be communication and emotional barriers.

A lack of proper hand-off report from one staff member to the next and nurses who appeared to feel overwhelmed and unsure of themselves or what to do next contributed to the patient being discharged to the wrong parent. Ways to decrease the presence of barriers and improve the staff interactions include a standardized hand off report, decreasing use of jargon or slang, giving timely feedback, decreasing physical barriers and talking in person, and learning about other cultures (Neusom, Ruby, n. d. ). Knowledge is power and the more the staff knows the better equipped they will be to identify and handle barriers as they arise.

Getting a team of nurses together from multiple departments to help develop a standardized hand off report for staff will ensure that important information is passed on and not missed. In this report, staff must relay vital information for that patient as well as give report in person so that technology and language are not barriers. This will allow the staff to work together to improve their areas and it allows them to take ownership of the project, meaning they will be more likely to utilize the hand off process in the future.

Another way to improve interactions is to include barriers as a topic of education in the annual risk management education that staff completes each year. By helping staff to see and identify potential barriers they can hopefully prevent them from impeding patient care in the future. Quality improvement Method The quality improvement is a concept that not only hospitals but companies all over the world have been using for a very long time. Quality improvement is the process of looking forward and backward at company, process, policy, and/or safety. It is simply the process of making things better or improving them.

It can be done to correct something that went wrong or used to prevent something bad from happening in the future. The method the Nightingale hospital needs to utilize is the FADE method. Focus, analyze, develop, and execute/evaluate (Wiseman, Beau and Kaprielian, Victoria S, 2005). While there are many different models available in the business world today, they all have the common theme of analysis, implementation and reviewing. Different businesses tend to have different needs and therefore no model is better than another. The FADE model is useful to the hospital’s root cause analysis as it gives guidance and direction.

The reason this model was chosen was because of the ease of use, the detailed direction and instruction, and the completeness of the model. This model allows the staff or committees to look at all angles of the situation and work to improve it. It is a complex model not a basic simple one, which gives better instruction. The first step of FADE is to focus. This means the hospital needs to identify a problem within the hospital and write a problem statement to help narrow down what is being looked at. The current issue is how to prevent child abductions within the hospital.

While the OR is where the current event happened, it can easily become an issue for other areas of the hospital who care for children. The next step is to analyze the data and determine influential factors. This means the hospital will need to compile lists of what information is important to this case and what information is not. Collect any data about patterns and things that influence the outcomes or contribute to the problem or solution. This is the time for the hospital to evaluate what went wrong that lead to the child being discharged to a person that potentially could have not been the child’s relative.

The more data that is gathered and analyzed the better understanding and better outcome the hospital can hope for in fixing the problem. The third step is to develop a plan of action. After gathering and reviewing all the information provided regarding the issue at hand. The hospital must develop a plan that helps to solve the problem. This is the time when getting people from multiple departments and areas of the hospital will be important as each area will have a different view point that may help develop a plan that works for the majority of the people.

During this stage not only does a plan need to be made but also planning to implement the plan. New policies and procedures cannot be implemented over night and expect all staff to agree and utilize it. All staff must complete proper training regarding the new plan before it can be put into use. For the hospital a plan needs to be developed that includes the input of security, OR staff, ER staff, OB staff, radiology, and administration. As multiple areas of the hospital will be affected by the new plan for pediatric patients, all those working with them should be included in the planning process.

Once a plan is developed to prevent child abduction from happening again, education of all staff will be required. The last step in the quality improvement method is execute and evaluation. After staff has been trained it is time to put the plan into action. This is the time when committees will need to be organized to continue to evaluate and monitor the progress of the plan, keep records of the impact the plan has, and most important execute the plan. As time passes the committees will need to continue to evaluate the plan for success.

If it is successful then continued monitoring is all that is needed. If the plan is not successful then the quality improvement methods starts again. It is during this phase that the hospital will need to ensure that every aspect of the plan is in place in a timely manner so that it can be properly evaluated. In this stage maintenance of the equipment and technologies will need to be completed as well as any minor adjustments to the plan that need to be made to better serve the entire staff and ensure the safety of the pediatric patients.

Overall quality improvement is vital to patient safety and necessary for the continued advancement and improvement of patient care. By utilizing this method the hospital will be able to complete a thorough root cause analysis that focuses, analyzes, develops, executes and evaluates the success and failure of the hospital. The Joint Commission requires that all sentinel events be reported and that the hospital develop a reason and solution to the problem. This method allows the hospital to follow Joint Commission Standards ensuring they keep their Joint Commission Accreditation.

Corrective Action Plan: The development of risk management officers and committees started when lawsuits and insurance premiums began to rise. The goal of these people was to establish guidelines in which to help reduce and prevent errors, increase safety, and decrease financial loss. While the committees work daily to accomplish these things by utilizing a process of identifying, analyzing, treating and controlling, and evaluating (Chubb Healthcare, n. d. ), it is important to note that all staff must take an active role in risk management to ensure the hospital maintains its high standards of care.

It is the responsibility of all staff to identify areas of concern and report to the risk management committee so that changes can be made. Annual education of all staff is required on this subject to ensure that everyone is doing all they can to decrease risk. A thorough risk management program includes policies and procedures on the running of a risk management committee as well as maintenance and changes to the company’s policies and procedures to ensure compliance and proper utilization. It also has formal incident reporting, tracking and trends, and staff education.

These are the basics of a very complex program that helps to decrease risk in the hospital setting. The areas that need to be changed and addressed in regards to the Nightingale Hospital is the area of policies and procedures that are related to patient safety. In ensuring patient safety the hospital can decrease the occurrence of lawsuits, decrease insurance costs, and increase staff awareness. While the risk management committee will be doing much of the initial review of the incident and changes to the policies, other committees and staff must be included in the change process.

These resources include quality assurance, administration, safety and security, legal, and nurses, physicians, and other ancillary staff. The risk management committee should be reviewing the hospitals policies and procedures on a routine basis, at least annually, to look for areas of improvement, compliance with Joint Commission standards, and changes in healthcare advancements that therefore make the policies outdated. This area of the risk management program is clearly not being followed if there is no policy or procedure in place to prevent child abductions from happening in areas outside of the OB department.

The risk management committee needs to address this lapse in protocol by taking five simple steps. First a review of the incident that happened, second gathering resources to help gain insight into the different areas of the hospital, third developing a new hospital policy, fourth implementing the policy and educating staff, and lastly reviewing the policy on a annual basis to ensure compliance and monitor the need for improvement (Chubb Healthcare, n. d. ). In doing these steps the risk management committee can decrease the potential for child abductions in the hospital.

First the committee must review the formal incident report, looking at the who, what, where, when, why, and how of the situation. Review any prior claims, patient complaints, staff complaints, and quality assurance reports (Chubb Healthcare, n. d. ). These allow the risk team to identify the problem and start to pinpoint the areas that need changing. The risk committee will need to work closely with the quality assurance committee, who likely have already gathered much of this information.

They also will be a resource with regards to the requirements of the Joint Commission standards and be able to help identify any missteps that are resulting in non-compliance. This step needs to be completed in a timely manner, the longer it takes to get the information the longer it will take to get a new policy in place. The risk committee should set a deadline of no more than one month to complete this step. It is more likely that the committee could complete this step in two weeks but as many members may be working on other projects at the time, the committee will be allowed one month to complete this step.

Next the risk management committee must meet with the different resources available to discuss the changes that need to be made to patient ensure safety. During this time the committee will hear from the legal department, safety and security department, staff from all areas of the hospital, and administrative staff. The point of this step is to gather as many ideas for change and improvement as possible from as many different aspects. As child abduction prevention is not just security’s responsibility it will be important to understand what all staff can do (CNA, 2006).

The legal department will be able to give feedback on what the hospital can and cannot do to ensure that the hospital does not develop a potential lawsuit from the new policy or lack of any previous policies. The safety and security department will be a huge resource for the risk committee as their job is to ensure that everyone stays safe. The new policy will greatly impact the security department as they will be required to potentially perform “code pink” drills, research and obtain new monitoring and sensor equipment or even increase staff levels to accommodate the increased security measures.

Ensuring that the safety and security department is working closely with the risk committee will be key to ensuring a policy that is beneficial to everyone. The administrative staff involvement will be important as they will be looking at the information from a corporate standpoint. Their input on the policy will be centered on what is best for the hospital and how it ties into the values and standards of the corporation as a whole. They also will know budgets available for changes that need to be made to staff or security systems.

The administrative resource is important because they look at the whole picture. The last resource that the risk committee will be utilizing is the staff, both clinical and non-clinical staff. This includes input from physicians, nurses, maintenance, environmental, technical support, and volunteers. These are the front line defenders when an abduction happens. These are the staff members that are present when it happens. Their input is key to being able to ensure that a new policy will help prevent any future abduction.

As these staff live the day-to-day responsibilities of caring for patients, their suggestions and points of view are important. Also by having staff involved in the planning process they will be more likely to adopt the new policy and follow it, because it will make sense to them and fit into their needs for the hospital. By utilizing all these different resources a proper policy can then be developed. This step should only take two weeks to complete. Taking longer may cause delay in development of the policy that is needed.

The thirds step is to develop the new hospital policy utilizing all the information gathered from the sentinel event, quality assurance committee, and the hospital resources. The new policy must meet Joint Commission requirements for standards of care and safety of patients, as well as the hospitals needs (Chubb Healthcare, n. d. ). During this time, research for any new technology or materials to implement the new policy must be completed and quotes for pricing submitted to administration for approval. When the risk committee writes the new policy it must be written in a way that everyone can understand.

This step should take no more than one month to complete. The committee should spend a week reviewing all the notes and information gathered from the first two steps, then one week gathering the pricing information needed to implement the plan and then two weeks to have a completed policy. Everyone on the committee and in administration must be aware of these deadlines so that the policy can be implemented in a timely manner and all approvals completed in the appropriate deadlines. Next, the risk committee must ensure the staff is educated on the new policy and implement the policy.

Live classes and computer-based learning will be important to educate all staff in the hospital on the new policy, technologies, and equipment (CNA, 2006). It is during this time that any new technology, forms, or other materials must be installed, printed, and dispersed so that when training is completed it will be ready for staff to use. This includes but is not limited to new forms for registration, new matching armbands for the children and parents, sensors around the hospital that connect with the sensors in the armbands of the children, increased security staffing, etc.

This step may take up to two months to complete depending on the ability of the committees to get the materials needed for training as well as materials installed and dispersed. Lastly the risk committee must continue to monitor the policy and compliance for any issues that may arise and make changes accordingly. It is recommended that with any new policy the risk committee monitor progress, compliance, and whether it is working or not by compiling risk reports on “code pinks” or other child safety reports as indicated in the policy monthly for the first year.

As the hospital becomes more comfortable with the policy and it is changed to fit the needs of the hospital, and the policy has not been changed for six months; the policy can go into the yearly review area. The quality assurance committee can then continue to monitor the policy for compliance, impact, and maintenance. This last step can take up to a year, if not longer to complete depending on the needs of the hospital. Conclusion In the end a child being abducted whether by a parent who does not have custody or by a stranger is an emotionally trying experience for any parent as well as the child.

All measures must be taken to ensure that the sentinel event does not occur again. By working with the quality assurance committee to utilize FADE (focus, analyze, develop, execute/evaluate), the risk management committee to create a new hospital policy, and the entire hospital staff, this will hopefully never happen again. While there are always legal and financial issues involved when something happens to a patient to compromise their safety, care, or well being, it is important that the hospital learns from these mistakes and takes action to correct them for the future.

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