Sentinel Event

Sentinel Event

A three year old Tina got admitted in the hospital OR for the purpose of bilateral myringotomy that was expected to last for approximately 45 minutes. After the surgery, Tina was going to be transferred to recovery so that to be monitored for at least one hour. The mother told the pre-op nurse that the she wanted to run a task that involved an older sibling of Tina. Therefore, she was going to leave the hospital immediately Tina was taken for surgery. Before leaving, Tina’s mother told the nurse that she had been going to come back on time. She was going to take Tina with her as soon as she was released from the recovery. She gave out her cell phone number, and she asked that they contact her in case the surgery on Tina would be completed early that she expected. After two and a half hours later, Tina’s mother went back to the hospital to pick her child, and she was extremely distressed to find out that the child had been discharged thirty minutes earlier.

The security in the hospital was notified at 0900 and the hospital child abduction alert was also initiated. The security informed the local police department in reporting the incidence. The security officer also noted that the parents of Tina had divorced and that Tina’s mother held full custody of the children. The local law enforcement located Tina in 30 minutes after the arrival of the mother. She was in the care of her father. The father had taken her to his home as they were waiting for the mother’s arrival.  There were no charges that were filed against the father of the child. The hospital’s CEO pledged to analyze the incident and then ensured the processes of the child’s mother would be put in place so that to prevent the recurring of the event.


Nightingale’s community hospital personnel played different roles in the sentinel event.

Prep-op nurse, Greta Doppke

The nurse prepared the patient for surgery, brought the patient and the mother in the prep operative area and completed the prep operative nursing assessment. The nurse later changed the patient into the hospital gown and started the patient IV. She administered the prep operative medications and documented them in the administration medication record the nurse later asked the mother of the child to sign the surgery consent form. The nurse later took the information on how to contact the mother after she said that she was going to be in hospital during the time of surgery. Greta then handed over the child to the OR nurse.

Security, Tim Blakely

The hospital security was contacted and informed about child abduction at approximately 0900. The security went to the Ambulatory surgery unit where he interviewed the nurse. During child discharge, the security had not been informed about the child discharge. The security also interviewed the mother of the child, and he found out that the parents to the child were divorced.

Registrar, Katie Jessup

The registrar worked with the mother of the patient during the time of admission when she was entering registration information. The registrar entered the insurance and demographic information in the electronic medical records. She took a copy of the insurance card and allowed the mother of the patient to sign the admission and treatment condition.

Chief nursing officer, Anna Liu Dilarno

The chief nursing officer was not involved in the sentinel event, but she was involved during the investigation process. She assisted in finding an excellent solution for the problem.

OR nurse, Rosemary Fry

Rosemary received the child from prep operative nurse, and she was available during the operation.

Surgeon, Carlos Munoz

The surgeon was involved in performing the surgery on the child. He had also examined the patient while in his office and took notes regarding the custody of the child. However, the surgeon did not share this information with any other staff member in the hospital. This is the reason as to why the problem was experienced because no one knew about the child custody.

Discharge nurse, Kim Johnson

The discharge nurse was responsible of discharging the child. The nurse brought the child when she was ready to live the hospital and waited for the patient’s mother at the waiting area. He was informed that the father of the patient was at the reception area and let the father in since the patient was crying. The nurse allowed the father to take the patient home after having waited for thirty minutes. The discharge nurse also communicated to the mother about the release of the patient on her arrival.

Recovery nurse, Jon Peters

The recovery nurse provided the patient with post anesthesia care after the surgery until she was ready for discharge. The nurse also received a report about the patient’s surgery from Rosemary. The recovery nurse called the waiting area for the mother of the patient when the patient started walking. The nurse then passed the patient to the discharge nurse.

Barriers that impede effective interaction

The largest barrier and the problem that affect effective interaction in the present personnel is a lack of a relevant protocol. Relevant protocols have not been put in place, and personnel are also busy with their roles. There are several incidences in the sentinel event where the communication process failed resulting to the situation. Curing the admission process, it was necessary for the person responsible to request for the office notes from the office of the surgeon and any other appropriate place. It was necessary for the mother to have been interviewed about the custody situation. It was determined that the father was not supposed to take the child; communications and protective barriers would have been put in place.

This task should have been done at the time of registration and not consuming extra nursing time during the pre operative process. The flow of information among the personnel was not done. After the pre op nurse had been informed that patient’s mother would not be around during the time of surgery, this is information that needed to be documented. This part of information should have been communicated to every person who gets involved with the treatment of the patient. Communication of the information should have been done verbally every time the patient was being passed from one department to another (Gwen, V 2009).  It would be essential if the pre op nurse had communicated the information with the recovery staff and the OR nurse.This would have helped in avoiding the patient from being discharged from their departments. The surgeon is apparently arrogant, a situation that has affected the communication process.

He should have provided a copy of notes about the patient from his office to the nurse instead of waiting for the nurses to request for the notes. The arrogance of the surgeon might what caused lack of communication between the nurse and physicians because of fear of verbal lashing or criticism. It would have been necessary for the OR nurse to search for information concerning the location of the patient. It would also be essential if this information was shared to the recovery nurse and the surgeon.The recovery nurse proves not to be responsible because he did not look further regarding the location of the patient’s mother, after realizing that she was not in the waiting room. Information about the location of the patient’s mother should have been communicated to the discharge nurse. The discharge nurse made a horrific mistake when she realized the patient to the non custodial parent. It is required of her to communicate to the pre op staff so that to determine how they would contact the mother of the patient, after finding out that she was not in the waiting room.

This is an indication that the discharge nurse was looking forward to discharging the patient so that she can go and do something else. It shows not being responsible and careful of whom is being left in charge of the patient. The nurse proves not to show any concern about the safety of the patient. The nurse proved this by allowing the patient to go with the father without confirming with the mother who brought the patient.Lack communication that is effective is one of the key barriers that resulted to the situation (Gwen, V 2009). The communication system was broken and each person in the hospital performed their responsibility without considering the safety of the patient. The discharge nurse has the responsibility to know who brought the patient to the hospital and who picks them up. In this case, the discharge nurse should have interrogated the father of the patient about the where about of the mother as she was the one who come with the patient for treatment. Communication is a process that is involved in information exchange between departments, individuals and organizations. This is an aspect that lacked in Nightingale community hospital.

Ways to improve interaction

The ways that can be used to improve interaction among the personnel is by establishing a communication system that will ensure that all information is available to every personnel in the hospital (Bryan, K 2009). Any information that personnel receive about a patient should be entered into the system. Open communication is extremely essential as it ensures that data is freely communicated. The nurses and doctors are free to communicate with one another can confirm information without fear. Doctors and nurses should show respect for each other and respect the role of each other in the organization (Bryan, K 2009).This will help in avoiding fear and people can communicate to each other without fear of being criticized. A protocol should be created regarding the steps that should be followed during the patient admission and their discharge. This will ensure that before the patient is discharged, the discharge nurse has to inform the personnel that admitted the patient so that to ensure safety of the patient. This will help in solving many problems in the hospital that tend to result due to negligence and poor communication.

Quality improvement method

The quality improvement method for this root cause analysis is process improvement. This is an essential aspect of quality improvement, and it should cover all the processes that are used in conducting the daily business operations. In health care, the main objective is to ensure high quality care is provided to the patient. The safety of the patient is also considered as it provides the patient with satisfaction with the services being offered (Fair, D & Lighter, D 2004). Process improvement will improve the overall satisfaction of the patient. Process improvement should include every aspect of the organization, and attention should be paid to the finest of details so that to ensure success.In order to improve the communication system in the organization, the organization should implement new communication techniques. They should also provide managers and employees with training in order to ensure the use of the latest techniques in improvement of services offered. This is an essential part in patient’s satisfaction as patients usually expect the latest techniques to be included in the services that they are receiving. Process improvement will ensure that customers receive quality care, and their concerns are addressed effectively. Process improvement is a method that is considered during quality improvement (Fair, D & Lighter, D 2004). In health care, every personnel should work together in ensuring the safety of the patient. This helps the organization to thrive. Constant attention should be offered at all times and willingness to implement new processes so that to promote success.

Risk management program

The risk management program that will ensure that the sentinel event does not happen again should cover the multiple areas so that to address this situation and the safety concern. The many methods of approaching the problem provide greater chances of preventing the situation from happening again. The corrective action should include all the areas that are included in the quality improvement method and process improvement. It should include training the personnel involved in the situation and creation of new protocols that utilize protective procedures and mechanisms to prevent this situation (Spiegel, A & Kavaler, F 2003).

The risk management program that will prevent recurrence of the event should include the following steps. The first step is determining the objectives to prevent. The objective to prevent includes damage to environment, financial losses to hospital because of legal claim, and patient exposure to injury. The second step is determining the main players and the people responsible of the implementation of the various steps when needed (Robert, Carroll 2011). The director of risk management and CEO of the organization should be responsible of the operation and implementation of the program.The third step is controlling the financial loss through making root cause analysis protocol and identification of the potential risks and claims. In order to control financial loss, quality improvement committee should be created, and creation of a procedure and protocol should be done for reporting incidents. The forth step involves reviewing the risk management program and making annual up dates. By covering these areas, the risk management program will be able to prevent another occurrence of such a sentinel event.


Bryan, K (2009). Communication in healthcare International Academic Publishers

Fair, D & Lighter, D (2004). Quality management in health care Jones & Bartlett Publishers, Inc

Gwen, V (2009). Communication skills for health care professional Jones & Bartlett Publishers, Inc

Robert, Carroll (2011). Risk management handbook for health care organization John Wiley & Sons

Spiegel, A & Kavaler, F (2003). Risk management in health care institution Jones & Bartlett Publishers, Inc

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