Hospital Sentinel Event Report
Program & Start Date: M.B.A. Health Care Management
A1: Sentinel Event Report
Minor child, Tina, had a minor operation and as told to child’s mother per Nightingale Memorial Hospital (NMH) pre-op nurse, the operation duration would be 45 minutes plus an additional hour in recovery.
Under the instruction of the patient’s mother, the pre-op nurse was to contact her by cell phone if times for release had changed.
Mother arrived approximately 2.5 hours later to pick up patient and found that her daughter had been released 30 minutes prior to her arrival.
At that point security issued a “Code Pink” (hospital-wide ...view middle of the document...
Ms. Doppke didn’t state if she relayed the special instructions to the staff that was responsible for releasing the patient. She stated that the surgery process lacked communication between the physician’s office and the hospital staff.
Rosemary Fry, O.R. Nurse: Ms. Fry was the operating room nurse present with the patient during the procedure and delivered the patient to the recovery nurse Peters. She expressed the need for better communication and universal policies throughout the hospital, this including security staff.
Carlos Munos, ENT Surgeon: Dr. Munos performed the surgery on pediatric patient. He stated that had the hospital staff requested the patient information from his office staff, they would have been provided with information stating the custody arrangement for the patient. He expressed concern for the safety of his patients due to negligence and requests reassurance that no other situation jeopardizing the well-being of his patients will happen again.
Jon Peters, Recovery Nurse: Mr. Peters' account of the incident offered no insight as to how this occurred and no ways to improve the procedures for discharging patients, specifically pediatric patients. Mr. Peters' further stated that an area competitor implements a formal hand off procedures to avoid incidents such as these, however discouraged it. Mr. Peters' stated he paged the mother throughout the facility but she didn't come.
Kim Johnson, Discharge Nurse: Ms. Johnson stated that she didn't know that the mother had sole custody of the child. She acknowledged that the pediatric patient recognized her father and assumed that after waiting approximately 30 minutes, she then allowed the father to take the patient. She was apologetic and urged better procedures for screening patient visitors.
Tim Blakely, Security Officer: Mr. Blakely was the first officer to respond to for child abduction call. He interviewed discharge nurse Johnson in regards to the incident. Ms. Johnson informed him that the child was missing for approximately 25 minutes prior to alerting security. He urged for a standard universal policy throughout the entire facility to avoid situations such as this and all staff is on the same page.
Ana Liu-Dilarno, Chief Nursing Officer: Ms. Liu-Dilarno had no involvement in the mentioned incident however wishes to be a part of the process in creating procedures in order to avoid any further situations involving her nursing staff.
A3. Personnel Issues
In light of the recent events, the most stated issue staff had was lack of communication throughout the entire facility among other staff members as well the referring provider’s offices. There was also a concern for the lack of policy regarding the check-in and discharge process for the safety of our pediatric patients. A few staff felt as if they had too many duties to be worried about any more and it should be the responsibility of other staff members to be concerned with the discharging of a pediatric...