Sentinel Event

A1. Sentinel issuing follow of the aesculapian exam record for the specified unhurried (SP) was completed 09/16/12. The health check record revealed that the SP was a minor babe with a diagnosis of history of frequent and recurrent tonsillitis and was scheduled to have the tonsils and adenoids retravel 09/14/12 at 1030 AM as an out uncomplaining of procedure. Review of the medical record for the day of 09/14/12 revealed that the SP was admitted to the pre-admission testing field of honor at 900 AM. At 1000 AM the SP was in the pre-operative orbit with the peripheral intravenous line in place and the pre-operative medications were being administered.At 1030 AM the SP was in the restrain dwell (OR) and the procedure was performed as scheduled. At 1115 AM, the SP was moved from the OR to the seat anaesthesia aid unit (PACU). At 1215 PM, the SP was successfully get from the procedure and some(prenominal) the sawb unmatchables and the anesthesio recordist cle ard the SP to go home. The medical record revealed a nourishs n maven by the pre-operative reserve on 09/14/12 at 1030 AM that documented a conversation between the pre-operative sustain and the SPs beat where the find bring forth tongue to she was leaving to run an errand involving an older sibling and left(a) strain field a cellular telephone issuance.The only documented instruction from the incur was for the nurse to call if the SP got out of mathematical process sooner than expected. In an call into question with the PACU nurse conducted on 09/15/12 at 1000 AM, the PACU nurse stated that on 09/14/12 at approximately 1230 PM, the persevering was released for home to her father, who was identified by his drivers license the PACU nurse stated that she provided written instructions for the patient roles post-operative care and follow up appointment to the father.The PACU nurse stated that the patients father verbalized chthonianstanding of the crystalize instructions and lef t with the patient. The medical record lacked certificate of this encounter. The medical record too lacked documentation of both restrictions as to which parent was permitted to take the patient home. The patients mother arrived at the hospital on 09/14/12 at approximately 100 PM to take the patient home and was super distraught when she discovered her daughter was not in the PACU as she expected.There was a hammock change at 100 PM and the oncoming nurses did not know that the patient was released to her father. As a result, warranter was called and a hospital-wide tiddler abduction alert ( calculate flagstonek) was activated. In addition to hospital security, local anaesthetic law enforcement was likewise notified of the missing nestling. The SPs mother told the hospital security officer that she and the SPs father were divorced and she had full bonds of the SP and the SPs siblings. On 09/14/12 at approximately 130 PM, the SP was located at the fathers residence, in t he care of the father.The SPs father stated that he took the SP to his residence to wait for the SPs mother to arrive. No charges were filed over against the SPs father. The hospital management and security forcefulness assured the SPs mother that this attendant would be investigated and wreakes would be swan in place to stop it from happening in the future. A2. Personnel There were several employees who had interactions with the SP and her mother during the outpatient hospital procedure. The first person was the hospital registrar who took the SPs demographic selective information from the SPs mother.The future(a) person was the pre-operative nurse who took compassed the SPs clinical breeding and medical history from the SPs mother, performed the initial physical assessment (height, weight, rattling signs, cardio-pulmonary, and head to toe), and obtained peripheral intravenous access. The people who then interacted with the SP were the surgeon, the anesthesiologist, and the operating room nurses. The surgeon also had an office visit with the SP and her mother in the geezerhood leading up to the surgery. The OR nurse took over care when the SP was moved from the pre-operative heavens to the OR.The OR nurse made the SP comfortable until she was under the anesthesia and began the retrieval process afterwards the surgery was completed. The next person who interacted with the SP was the post anesthesia care unit (PACU) nurse. The PACU nurse was amenable for monitoring the SP during the recovery phase when she was coming out from under the anesthesia. During the post anesthesia phase, the surgeon and the SP assessed and evaluated the SP. Both the surgeon and the anesthesiologist had to sign the papers to release the patient to the discharge nurse. Finally, the patient was transferred to the care of the discharge nurse.The discharge nurse released the SP to her father. after the SPs mother came back to the hospital and shrouded the SP was missing, t he Chief care for police officer (CNO) was immediately involved. The CNO met with the SPs mother and alerted the security team and local police to the disappearance of the baby. The local police were able to locate the SP at her fathers house approximately 30 minutes after she was reported missing. The CNO had the responsibility to the SPs mother to launch the investigation into the energize of her disappearance and to implement a plan of correction so the incident could be pr featureed in the future. A3.Personnel Issues Several factors negatively affected the coordination of patient care by the employees on 09/14/12. First, the communication between the admission personnel and the SPs mother was ineffective when the registrar failed to obtain screen training and/or ask about whatsoever custody situation. Second, the pre-operative nurse did obtain the custody information and the mothers cellular telephone number and documented these on her clip board. However, the pre-operat ive nurse failed to report this as of the essence(predicate) information to the operating room nurse upon transfer of the SP from the pre-operative theatre of operations to the operating room.As a result, the operating room nurse did not alert the PACU nurse to this important information upon transfer of the SP from the OR to the PACU area. The hospital failed to have open off policies and procedures in place when a patient was moved from one area of surgery to another. They depended solely on their electronic record and did not have any reporting requirements in place when a patient was moved from the admission to pre-operative to operative to post-operative areas. There was a cultural/ terminology barrier between the PACU nurse and the Hispanic discharge nurse devising verbal communication very difficult.Other factors of poor communication were mental facultying ratios and the perspectives and posts of the module. In interviews conducted with the registrar, the pre-operativ e nurse, the PACU nurse, and the discharge nurse after the observation post event, they all had a negative, finger pointing attitude of doing the minimum to get by and not taking responsibility for the observation post event. There was also a cumulative feeling among the rung of headache of reprimand or of being ignored in expressing thoughts about the security of pediatric patients in the surgery area, Organizational structure has a direct impact n the communication within an ecesis. The way the hierarchy of an organization is designed either invites feedback, open-mindedness and effective communication or stifles, controls and restricts the ability of subordinates to freely express thoughts, feelings and ideas (Papa 2012). In the post sentinel event interview, the pre-operative nurse expressed an idea about matching hospital radiocarpal joint bands for both the pincer and the parent. This was a good idea, but no system for matching wrist bands was in place.The pre-operati ve and post-operative areas were understaffed that day making communication among the nurses hurried and ineffective, at last creating gaps in communication and contributing to the sentinel event. The fact that the working(a) area was so short staffed left very little clock time for the nurses to give hand off reports. As a result, many important exposit were overlooked. The CNO failed to ensure that the required monthly staffing encounters were held among the surgical team members.Finally, the security personnel were not even called for several minutes after the SP was reported as missing and the security manager failed to perform the code pink child abduction drills on a quarterly basis as required by the hospitals form _or_ system of government. A3a. Improve Interactions The initiative to improve interactions among the personnel operative on 09/14/12 include a modern insurance policy use on 10/01/12 regarding obtaining custody information and privacy information at the point of registration for any minor child whether it is in the emergency room, inpatient, or outpatient areas of the hospital.This policy include a agreement that three things are realized a numerate of people who are permitted private information, a list of people who are permitted to take the patient out of the hospital, and a tetrad digit pin number established by the parent. Information and/or the patient themselves volition only be released strictly to a person who is both on the privacy list and who have the pin number. A policy and procedure was also implemented on 10/01/12 in the outpatient surgery area which included detailed procedures for patient hand off when the patient was moved from one area to the next.A new-fangled patient hand off form was created which included basic demographic data, medical history, allergies, medication profile, the privacy list, pin number, and any other pertinent custody information for minor children. The registrar essential document that both a verbal report and the written report were given to the pre-operative nurse. The pre-operative nurse must then document this same information was relayed both verbally and in writing to the OR nurse and the OR nurse is also required to document this same information was relayed both verbally and in writing to the PACU nurse.The hand off forms must be signed by both the person reporting off and the person receiving the report and filed in the patients paper chart or scanned into the patients electronic medical record. A mandatory in-service meeting for all staff was held on 09/28/12 to t separately the staff the new policy and procedures. Also, the required monthly staff meetings for the entire surgical team (including physicians) go away be implemented to serve as a town hall approach discussion to get any complaints or suggestions by the staff out in the open.In addition to the monthly staff meeting, there will be required in-service didactics for the staff for the nex t twelve months including patient safety, child abduction prevention, improvisational workshops to prompt discussion among staff, patient hand-off, time out before discharge, patient rights, diversity training, verbal communication, nonverbal communication, shift change reporting, patient satisfaction, and patient education. A4. Quality betterment The identification and data gathering quality improvement method was used in the motif cause synopsis of the sentinel event.First the problem was identified the processes needing improvement were pediatric safety and staff communication. These processes were identified through the post sentinel event interviews of the staff, administrative staff post sentinel event huddles, and surgery staff post sentinel event huddle (including security staff). The data was gather from the SPs medical records and a timeline was created kickoff when the SP entered the hospital and ending when the SP left the hospital with her father. This timeline inc luded an analysis of what was actually done by severally employee and also what should have been done to prevent the sentinel event.The question of why was asked when inactions were determined to be what resulted in the sentinel event. Along with the SPs medical record, all other medical records for minor children who received outpatient surgery at the hospital during the first two weeks in September were also examine to determine that the inactions on the part of the outpatient surgery staff were a general problem and that this was not an isolated case. Staffing ratio policies were reviewed and security policies on code pink drills were also reviewed.Staff meetings were held hebdomadal where feedback was provided to staff during the source cause analysis process regarding performance indicators and benchmarking against other hospitals of similar size in the areas of patient hand offs, staff to patient ratios and performance of security drills including child abduction drills. afterward the data was self-possessed, all involved in the sentinel event were gathered and a list of causes of the sentinel event was created. This list was used in creating the recommendations to improve staff communication and creating the process change to ensure that the sentinel even does not recur.B1. Risk Management Program The process of obtaining custody information and privacy information at the point of registration for any minor child, in all areas of the hospital, will be managed and directed by the head Quality Improvement incumbent of the hospital. The new policy also has a requirement to prevent the sentinel event from happening again at the point of registration any minor child under the age of 18 will have a bar-coded band put on their wrist or if they are less than four days old, on their ankle.The parent(s) or good guardian(s) will be required to enter a wrist band with a matching bar code. in the first place the child is discharged home, both wrist bands will be scanned with the data processor bar code scanner to ensure the wrist bands match. Only the parent(s) or guardian(s) with proof of legal custody will have the wrist band. Additionally, at the point of registration, the parent(s) or guardian(s) will be asked to choose a four digit pin number which will be noted in the electronic medical record under the security tab.At the point of discharge, the parent(s) or guardian(s) will be required to give the four digit pin number before the child is released to them for discharge. These measures are to be implemented by 10/05/12 with 100% compliance expected by 10/12/12. Starting on 10/05/12, the Quality Improvement Officer will audit 25% of all admission paperwork on a weekly basis to ensure compliance with the new policy. The Quality Improvement Officer will restrict a log of this audit process and the outcomes of the audits. If a registrar is found to be out of compliance with the requirement, corrective action will occur.Startin g 10/05/12, the Nurse tutor of the outpatient surgery area is required to audit 25% of the outpatient medical records on a weekly basis for compliance with the new patient hand off policy and procedure which applies to adult and minor child patients. She will also keep a log of this audit process and the outcomes of the audits. The Quality Improvement Officer and the Nurse Manager of the outpatient surgery area will hold bi-weekly meetings with the heads of distributively department in the hospital to review the audit results and to obtain feedback from each department regarding the new policies and procedures.The Nurse Manager of the outpatient surgery area will hold bi-weekly meetings with the outpatient surgery staff to review the audit results and to obtain feedback on the new admission process for minor children and the new patient hand off process for all patients. Starting 10/01/12, the Nurse Manager of the outpatient surgery area will also be responsible for nearly monito ring the daily staffing ratios and ensuring that adequate to(predicate) staff is working during each shift.Also starting 10/01/12, the head of the security department will be responsible for performing the code pink drills monthly and documenting these in the security log book. New security cameras will also be installed in the outpatient surgery area, at all exit doors, by 10/12/12. B1a. Resources The resources need to support the changes to prevent the sentinel event from recurring are the medical staff, corporate compliance staff, administrative staff, human resources, and outside compliance consultants.The legal team was immediately involved in the sentinel event to diminish the risk involved in an event such as child abduction. The finance department will provide the financial resources to purchase the new bar coded band system and the new security cameras. The staff will need to be trained on the new policies and procedures by the education department. Also, it is essential that each shift and each department have an adequate staffing ratio which is the responsibility of the hospital administration and the CNO.Human resources, administration, and the CNO were involved in interviewing and commission the staff involved in the sentinel event. They will have an on-going responsibility to follow up with the staff to ensure compliance with the new policies and procedures. Outside compliance consultants were also utilized in completing the root cause analysis, creation of the plan of correction, and implementing the plan of correction. C. Sources Papa, J. (2012, May 9). General format. Retrieved from http//www. ehow. com/about_6071356_communication-organizational-structure. hypertext markup language