Sentinel Event

A1. talent sc stunned Event Review of the checkup embark for the specified enduring (SP) was completed 09/16/12. The medical record revealed that the SP was a pocketable child with a diagnosis of peeleds wrap up of frequent and recurrent tonsillitis and was scheduled to hurl the tonsils and adenoids removed 09/14/12 at 1030 AM as an give away enduring procedure. Review of the medical record for the day of 09/14/12 revealed that the SP was admitted to the pre- gate testing field of view at 900 AM. At 1000 AM the SP was in the pre-operative area with the peripheral intravenous line in place and the pre-operative medications were being administered.At 1030 AM the SP was in the operating room (OR) and the procedure was performed as scheduled. At 1115 AM, the SP was moved from the OR to the abide anesthesia care unit (PACU). At 1215 PM, the SP was successfully recovered from the procedure and both the surgeon and the anesthesiologist cleared the SP to go home. The medical rec ord revealed a sucks note by the pre-operative nurse on 09/14/12 at 1030 AM that documented a conversation between the pre-operative nurse and the SPs incur where the get under sensations skin stated she was leaving to run an errand involving an older sibling and left a cellular telephone number.The scarcely documented instruction from the grow was for the nurse to c whole if the SP got out of surgery sooner than expected. In an reference 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 affected role was rund for home to her beginner, who was identified by his device drivers license the PACU nurse stated that she provided written instructions for the patients post-operative care and equal up appointment to the yield.The PACU nurse stated that the patients father verbalized understanding of the acquittance instructions and left with the patient. The medical record lacked documentation of this encou nter. The medical record likewise lacked documentation of all restrictions as to which parent was permitted to take the patient home. The patients set out arrived at the hospital on 09/14/12 at approximately 100 PM to take the patient home and was passing distraught when she discovered her daughter was not in the PACU as she expected. in that respect was a shift change at 100 PM and the oncoming nurses did not know that the patient was released to her father. As a result, tribute was called and a hospital-wide child abduction alert (code pink) was activated. In addition to hospital bail, local law enforcement was also notified of the missing child. The SPs mother told the hospital security officer that she and the SPs father were divorced and she had full clasp of the SP and the SPs siblings. On 09/14/12 at approximately 130 PM, the SP was located at the fathers residence, in the 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 once against the SPs father. The hospital management and security military group assured the SPs mother that this disaster would be investigated and processes would be put in place to pr core it from happening in the future. A2. personnel department 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 cultivation from the SPs mother.The next person was the pre-operative nurse who took obtained the SPs clinical education and medical history from the SPs mother, performed the initial physical assessment (height, weight, vital signs, cardio-pulmonary, and head to toe), and obtained peripheral intravenous access. The people who therefore 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 day s wind up to the surgery. The OR nurse took over care when the SP was moved from the pre-operative area to the OR.The OR nurse make the SP comfortable until she was under the anesthesia and began the recovery process after the surgery was completed. The next person who interacted with the SP was the post anesthesia care unit (PACU) nurse. The PACU nurse was responsible 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 news reports 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 crossed the SP was missing, the Chief Nursing ships officer (CNO) was immediately involved. The CNO met with the SPs mother and alerted the se curity team and local police to the disappearance of the child. 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 state to the SPs mother to launch the investigation into the throw of her disappearance and to implement a pattern of correction so the incident could be prevented in the future. A3.Personnel Issues Several factors negatively affected the coordination of patient care by the employees on 09/14/12. First, the confabulation between the admission personnel and the SPs mother was in undecomposed when the registrar failed to obtain silence education and/or ask about any 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-operative nurse failed to report this as important information to the operating room nurse upon transfer of the SP from the pre-operat ive area 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 hand 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 reportage requirements in place when a patient was moved from the admission to pre-operative to operative to post-operative areas. There was a ethnic/language barrier between the PACU nurse and the Hispanic discharge nurse making verbal communicating very difficult.Other factors of poor communication were moduleing balances and the perspectives and attitudes of the cater. In interviews conducted with the registrar, the pre-operative nurse, the PACU nurse, and the discharge nurse after the sentinel event, they all had a negative, finger pointing attitude of doing the minimum to get by and not taking resp onsibility for the sentinel event. There was also a cumulative feeling among the supply of fear of reprimand or of being ignored in expressing thoughts about the security of pediatric patients in the surgery area, Organizational structure has a carry on impact n the communication within an organization. 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 child and the parent. This was a good idea, but no body for matching wrist bands was in place.The pre-operative and post-operative areas were understaffed that day making communication among the nurses hurried and ineffective, ultimately creating gaps in communication and contributing to the sentinel event. The fact that the surgical area was so short staffed left very little time for the nurses to give hand off reports. As a result, many important details were overlooked. The CNO failed to ensure that the postulate monthly staffing meetings 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 managing director failed to perform the code pink child abduction drills on a quarterly basis as compulsory by the hospitals policy. A3a. Improve Interactions The initiative to improve interactions among the personnel working on 09/14/12 included a new policy enforced on 10/01/12 regarding obtaining custody information and concealment information at the point of registration for any lowly child whether it is in the emergency room, inpatient, or outpatient areas of the hospital.This policy included a stipulation that three things are established a list of people who are permitted private information, a list of people who are permitted to take the patient out of the hospital, and a four digit pin number established by the parent. Information and/or the patient themselves allow for 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 patient hand off form was created which included prefatory demographic data, medical history, allergies, medication profile, the privacy list, pin number, and any other pertinent custody information for minor children. The registrar must 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 al so 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 teach the staff the new policy and procedures. Also, the required monthly staff meetings for the entire surgical team (including physicians) exit 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 leave alone be required in-service education for the staff for the next twelve months including patient safety, child abduction prevention, improvisational workshops to prompt discussion among staff, patient hand-off, time out beforehand discharge, patient rights, diversity training, verbal communicatio n, nonverbal communication, shift change reporting, patient satisfaction, and patient education. A4. Quality return The identification and data gathering quality improvement method was used in the root cause summary of the sentinel event.First the problem was identified the processes needing improvement were pediatric safety and staff communication. These processes were identified through with(predicate) 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 gathered from the SPs medical records and a timeline was created starting when the SP entered the hospital and ending when the SP left the hospital with her father. This timeline included an analysis of what was actually done by each employee and also what should have been done to prevent the sentinel event.The question of why was asked when inactions were see to itd to be what resulted in the sen tinel event. Along with the SPs medical record, all other medical records for minor children who sure outpatient surgery at the hospital during the first two weeks in September were also analyzed to determine that the inactions on the part of the outpatient surgery staff were a systemic 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 weekly where feedback was provided to staff during the root 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. After the data was gathered, 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 pr ocess change to ensure that the sentinel even does not recur.B1. Risk Management platform 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 police officer 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 years old, on their ankle.The parent(s) or legal guardian(s) will be required to wear a wrist band with a matching bar code. Before the child is discharged home, both wrist bands will be scanned with the computer bar code scanner to ensure the wrist bands match. Only the parent(s) or guardian(s) with check 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 line on 10/05/12, the Quality Improvement Officer will take stock 25% of all admission paperwork on a weekly basis to ensure compliance with the new policy. The Quality Improvement Officer will keep 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, disciplinary action will occur.Starting 10/05/12, the Nurse carriage 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 patient s. She will also keep a log of this audit process and the outcomes of the audits. The Quality Improvement Officer and the Nurse passenger car of the outpatient surgery area will admiration bi-weekly meetings with the heads of each 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 closely monitoring the daily staffing ratios and ensuring that tolerable 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 th e 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 needed to support the changes to prevent the sentinel event from recurring are the medical staff, unified compliance staff, administrative staff, human resources, and outside compliance consultants.The legal team was immediately involved in the sentinel event to minimize 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 counseling the staff involved in the sent inel event. They will have an ongoing responsibility to follow up with the staff to ensure compliance with the new policies and procedures. distant 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. html