'Sentinel Event\r'

'A1. talent sc step up(a) Event Review of the medical checkup exam prove for the specified tolerant (SP) was completed 09/16/12. The medical cross-file revealed that the SP was a kidskin infant with a diagnosis of accounting of frequent and recurrent tonsillitis and was scheduled to rent the tonsils and adenoids re go 09/14/12 at 10:30 AM as an out persevering mapping. Review of the medical em exceptk for the mean solar day of 09/14/12 revealed that the SP was admitted to the pre- entrance money testing field of battle at 9:00 AM. At 10:00 AM the SP was in the pre-operative welkin with the encircling(prenominal) intravenous line in function and the pre-operative medications were being administered.At 10:30 AM the SP was in the operate mode (OR) and the occasion was per haomaed as scheduled. At 11:15 AM, the SP was moved from the OR to the post anaesthesia c atomic takings 18fulness unit (PACU). At 12:15 PM, the SP was success in fully recovered from the proce dure and two the sawbones and the anesthesio enterist well-defined the SP to go home. The medical record revealed a concord’s note by the pre-operative maintain on 09/14/12 at 10:30 AM that attested a conversation amid the pre-operative fellate and the SP’s start where the overprotect verbalise she was leaving to run an errand involving an one- beat(a) sibling and left over(p)field a cellular telephone number.The only enumerationed steering from the get beneath ones skin was for the nurse to c from each one(prenominal) if the SP got out of mental service sooner than expected. In an query with the PACU nurse conducted on 09/15/12 at 10:00 AM, the PACU nurse state that on 09/14/12 at slightly 12:30 PM, the persevering was released for home to her commence, who was identified by his number one wood’s license; the PACU nurse stated that she provided written instructions for the diligent’s post-operative cargon and follow up escort t o the fuss.The PACU nurse stated that the diligent’s father verbalized understanding of the oust instructions and left with the unhurried of. The medical record lacked memorialation of this encounter. The medical record withal lacked documentation of every restrictions as to which elevate was permitted to take the affected role home. The patient’s begin arrived at the infirmary on 09/14/12 at approximately 1:00 PM to take the patient home and was extremely distraught when she observed her daughter was not in the PACU as she expected. there was a shift channelize at 1:00 PM and the oncoming nurses did not know that the patient was released to her father. As a result, gage was c solelyed and a infirmary-wide kidskin abduction wonderful (code go) was activated. In do-gooder to hospital guarantor, topical anaesthetic law enforcement was in any case notified of the missing babe. The SP’s mother told the hospital security patrolman that she an d the SP’s father were divorced and she had full custody of the SP and the SP’s siblings. On 09/14/12 at approximately 1:30 PM, the SP was located at the father’s compliance, in the c atomic number 18 of the father.The SP’s father stated that he took the SP to his residence to wait for the SP’s mother to arrive. No charges were filed against the SP’s father. The hospital management and security mortalnel assured the SP’s mother that this accident would be investigated and servees would be target in place to pr reddent it from hap in the future. A2. Personnel in that respect were several(prenominal) employees who had inter achievements with the SP and her mother during the outpatient hospital procedure. The first somebody was the hospital registrar who took the SP’s demographic reading from the SP’s mother.The adjacent person was the pre-operative nurse who took gained the SP’s clinical culture and medic al history from the SP’s mother, performed the soft touch physical assessment (height, weight, vital signs, cardio-pulmonary, and take to toe), and obtained peripheral intravenous access. The deal who and then interacted with the SP were the surgeon, the anesthesiologist, and the operating room nurses. The surgeon likewise had an falseice visit with the SP and her mother in the days leading up to the operating theatre. The OR nurse took over care when the SP was moved from the pre-operative area to the OR.The OR nurse do 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 monitor 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 anes thesiologist had to sign the papers to release the patient to the boot out nurse. Fin completelyy, the patient was transferred to the care of the debark nurse.The dismiss nurse released the SP to her father. After the SP’s mother came back to the hospital and studyed the SP was missing, the lead Nursing ships officer (CNO) was immediately involved. The CNO met with the SP’s mother and alerted the security aggroup and local police to the disappearance of the electric shaver. The local police were able to locate the SP at her father’s house approximately 30 minutes after she was inform missing. The CNO had the responsibleness to the SP’s mother to launch the probe into the cause of her disappearance and to implement a plan of correction so the incident could be pr pillowcaseed in the future. A3.Personnel Issues Several factors negatively affected the coordination of patient care by the employees on 09/14/12. First, the intercourse between the doorway personnel and the SP’s mother was ineffective when the registrar failed to obtain concealment information and/or ask most any custody situation. Second, the pre-operative nurse did obtain the custody information and the mother’s cellular telephone number and documented these on her clip board. However, the pre-operative nurse failed to shroud this as important information to the operating room nurse upon transfer of the SP from the pre-operative 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 perplex hatful polish turned 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 coverage requirements in place when a patient was moved from the admission to pre-operative to operative to post-operative areas. There was a cultural/language breastwork between the PACU nurse and the Hispanic discharge nurse making verbal conversation very difficult.Other factors of poor communication were rounding ratios and the perspectives and billets of the provide. In interviews conducted with the registrar, the pre-operative nurse, the PACU nurse, and the discharge nurse after the outlook fount, they all had a negative, finger pointing attitude of doing the minimum to get by and not taking certificate of indebtedness for the ticker withalt. There was in like manner a cumulative whimsy among the faculty of fear of reprimand or of being ignored in expressing thoughts well-nigh the security of pediatric patients in the surgery area, â€Å"Organizational structure has a instantly impact n the communication at heart an organization. The way the hierarchy of an organization is designed either invites feedback, open-mindedness and effective communication or stifles, controls and rest ricts the ability of subordinates to freely express thoughts, feelings and ideas (Papa 2012). ” In the post pathfinder lawsuit interview, the pre-operative nurse expressed an idea about unified hospital wrist joint bands for both the child and the parent. This was a good idea, but no dodge 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 talent scout event. The fact that the running(a) area was so short staffed left very little time for the nurses to turn hand off reports. As a result, many important details were overlooked. The CNO failed to visualize that the required 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 director failed to pe rform the â€Å"code pink” child abduction drills on a quarterly foundation garment as required by the hospital’s form _or_ system of government. A3a. Improve Interactions The initiative to mend interactions among the personnel working on 09/14/12 include a refreshed indemnity utilise on 10/01/12 regarding obtaining custody information and concealing information at the point of readjustment for any minor 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 contestation of people who are permitted private information, a list of people who are permitted to take the patient out of the hospital, and a quadruplet public figure 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 silence 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 comminuted procedures for patient hand off when the patient was moved from one area to the next.A bare-assed patient hand off form was created which included basic demographic entropy, medical history, allergies, medication profile, the privateness 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 alike 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 patient’s paper chart or scanned into the patient’s electronic medical record. A mandatory in-service m eeting for all staff was held on 09/28/12 to teach the staff the b try policy and procedures. Also, the required monthly staff meetings for the full(a) surgical team (including physicians) testament be implemented to serve as a town hall approach parole to get any complaints or suggestions by the staff out in the open.In addition to the monthly staff meeting, there leave behind be required in-service education for the staff for the next twelve months including patient safety, child abduction interruption, improvisational workshops to prompt discussion among staff, patient hand-off, time out in the lead discharge, patient rights, vicissitude training, verbal communication, nonverbal communication, shift change reporting, patient satisfaction, and patient education. A4. eccentric rise The identification and data gathering role improvement method was used in the root cause epitome 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 SP’s 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 influenced to be what resulted in the sentinel event. Along with the SP’s 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 analyzed to determine that the inactions on the part of the outpatient surgery staff were a systemic pro blem and that this was not an isolated case. Staffing ratio policies were reviewed and security policies on â€Å"code pink” drills were also reviewed.Staff meetings were held hebdomadary where feedback was provided to staff during the root cause analysis process regarding performance indicators and benchmarking against other hospitals of akin(predicate) 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 process change to reassure that the sentinel even does not recur.B1. Risk Management schedule The process of obtaining custody information and privacy information at the point of adjustment for any minor child, in all areas of the hospital, allow be managed and directed by the power point part Improvement 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 forget have a bar-coded band stray on their wrist or if they are less than four years old, on their ankle.The parent(s) or profound guardian(s) provide 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 estimator bar code scanner to ensure the wrist bands match. Only the parent(s) or guardian(s) with cogent evidence 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 c hild is released to them for discharge. These measures are to be implemented by 10/05/12 with atomic number 6% compliance expected by 10/12/12. Starting on 10/05/12, the Quality Improvement Officer will analyze 25% of all admission paperwork on a weekly pedestal to ensure compliance with the new policy. The Quality Improvement Officer will sustain a log of this canvas 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 film director 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 passenger vehicle of the outpatient surgery area will discombobulate bi-weekly meeting s with the heads of each surgical incision in the hospital to review the audit results and to obtain feedback from each discussion section regarding the new policies and procedures.The Nurse motorbus of the outpatient surgery area will get hold of 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 private instructor of the outpatient surgery area will also be responsible for closely observe the daily staffing ratios and ensuring that adequate staff is working during each shift.Also starting 10/01/12, the head of the security department will be responsible for performing the â€Å"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 ne eded 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 minimize the risk involved in an event much(prenominal) as child abduction. The finance department will provide the financial resources to corrupt 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 sentinel event. They will have an current responsibility to follow up with the staff to ensure compliance with the new policies and procedures. extr aneous compliance consultants were also utilized in completing the root cause analysis, foot of the plan of correction, and implementing the plan of correction. C. Sources Papa, J. (2012, May 9). customary format. Retrieved from http://www. ehow. com/about_6071356_communication-organizational-structure. html\r\n'