RCA (ROOT CAUSE ANALYSIS)
FOR THE SENTINEL EVENT STATEMENT
HAPPENED ON MAY 14,
THURSDAY IN 9: 00 AM.
1 . SENTINEL CELEBRATION DESCRIPTION.
The pre-op nurse told the mom that once Tina (The patient), a 3 years outdated child, traveled to the OR, her surgical procedure would take about forty five minutes and then she'd go to recovery and she would be generally there at least one hour. The mother advised the nurse that once Tina went to the OR, she required to run a quick errand involving an older sibling and could return on time to pick her up once she acquired out of recovery. The mother provided the pre-op nurse her cell phone number with instructions to make contact with her in the event Tina received out of surgery sooner than expected.
Tina's mother returned to pick her about 2 ВЅ hours after and found that Tina was discharged half an hour earlier.
Tina's mom was really distraught, secureness was referred to as, and a " Code PinkвЂќ (hospital-wide child kidnapping alert) was activated. Community law enforcement was also approached by hospital security. When the security officer interviewed the mom, she distributed to him that she and Tina's father were divorced and that she had complete custody of Tina and her brothers and sisters.
Barre?o was located within thirty minutes of her mother's introduction, by neighborhood law enforcement, inside the care of her father. He previously taken her to his home to await the arrival with the mother. Expenses were recorded against the dad.
2 . EMPLOYEES ROLES PRESENT DURING THE SENTINEL EVENT.
1 . PREP-OP REGISTERED NURSE.
Prepared patient for surgical treatment, brought the mother and daughter (Patient) to the prep-operative area, completed the prep-operative nursing analysis, changed the patient to a medical center gown, began the patient 4, administered the prep-op prescription drugs, documented inside the administration medication record, asked the mom to indication the approval form to get surgery, took the mom's name and cell phone number, the mother pointed out that she could be gone throughout the surgery for quite a while, and to please give her a contact when the surgery was carried out, but that she needs to be back when the medical procedures should be done. The lady didn't ask for legal guardianship or guardianship, because it basically one of the questions in the breastfeeding assessment form.
Later on, the girl took the individual back to OR and passed the patient towards the OR health professional, but the girl never passed any information for the OR health professional about the mother going out of for a while, during the surgery, likewise no contact about the mother was ever approved.
2 . OR NURSE.
Received the patient from your prep-op nurse, without receiving any information about the situation with the mother leaving while the daughter will be in surgery, no titles and contact numbers weren't likewise given.
a few. RECOVERY NURSE.
After the sufferer come out of medical procedures, the OR nurse helped bring the patient to him, the OR health professional gave him the report about the patient's surgical treatment, provided individual with post-anesthesia care till the patient was ready to go for the ambulatory surgical unit, post-operative area to get ready the patient intended for discharge.
When the patient awoke, he paged the mother in the ready area, as well as the mother by no means responded, this individual stayed with the sufferer till was time to take the patient to the discharge doctor.
some. DISCHARGE NURSE.
She received the patient in the recovery doctor, because the individual was all set to go home, the recovery nurse mentioned to her that this individual paged the mother, nevertheless she failed to respond and she didn't show up, in those days the relieve nurse did not know what to complete. Then, she received a call in the security officer, showing her which the patient's daddy was at the waiting location, she allowed the father to come to the release area to see his child, she hear when the affected person called him daddy and she sensed better to know that a family member just visited the hospital, the lady waited another 30 minutes and the mother...