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DLG AA Task 2.docx Code Pink Sentinel Event Root Cause Analysis College of Business, Western Governors University AFT2: Accreditation Audit Code Pink Sentinel Event Root Cause Analysis Sentinel Event Summary A sentinel event occurred at Nightinga$7.49
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DLG AA Task 2.docx Code Pink Sentinel Event Root Cause Analysis College of Business, Western Governors University AFT2: Accreditation Audit Code Pink Sentinel Event Root Cause Analysis Sentinel Event Summary A sentinel event occurred at Nightinga
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DLG AA Task Code Pink Sentinel Event Root Cause Analysis College of Business, Western Governors University AFT2: Accreditation Audit Code Pink Sentinel Event Root Cause Analysis Sentinel Event Summary A sentinel event occurred at Nightingale Community Hospital (NCH) on Thursday, September...
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Code Pink Sentinel Event Root Cause Analysis
College of Business, Western Governors University
AFT2: Accreditation Audit
Code Pink Sentinel Event Root Cause Analysis
Sentinel Event Summary
A sentinel event occurred at Nightingale Community Hospital (NCH) on Thursday,
September 14 at 12:30 p.m. On this date, a 3-year-old female (3 y/o) arrived at NCH’s
Ambulatory Surgical Unit with her mother. Upon arrival, the patient was directed to the
registrar’s desk, where the 3 y/o was registered for her procedure, a dual bilateral myringotomy
(tubes in the ears). Once registration was completed, they were taken to the pre-op area for the 3
y/o to be prepped for surgery. The mother was informed that the surgery would take
approximately 45 minutes to perform and then the 3 y/o would be transferred to recovery where
she would spend approximately one hour. At this time, the mother informed the pre-op nurse that
she had an errand to do for an older sibling. She provided the nurse with her phone number and
requested a call if the surgery ended sooner than planned. However, she did state that she would
return to pick up the 3 y/o when she was out of recovery.
2.5 hours later, the mother returned to the hospital. This is approximately 45 minutes after
surgery and recovery time was completed. Upon her arrival, the discharge nurse revealed that the
3 y/o had already been discharged approximately 30 minutes earlier, to a man claiming to be her
father. The mother became incredibly distraught, explaining that she was divorced from her
father and had sole custody of the three y/o. Security was called immediately, and a “Code Pink,”
(NCH's indication of child abduction) was issued hospital-wide. Additionally, a call was made to
local law enforcement who was notified of the apparent abduction.
The result of the event is that local law enforcement found the 3 y/o at the father's home
within 30 minutes, where they were waiting for the mother to arrive.
, Personnel
NCH's CEO spoke to the mother and assured her that this event would be investigated by
the hospital. Additionally, he assured her that new procedures would be created and changed to
prevent a similar event from occurring in the future. In compliance with his assurances, any
hospital personnel that was involved with the sentinel event were interviewed, as well as senior
personnel that should be involved in the creation and training of personnel to prevent such an
event from occurring again.
Registrar
It is the registrar’s responsibility to check-in the patient, collect insurance information,
and has the patient or a guardian sign all appropriate documents. The registrar then passes the
patient on to the pre-op (PO) nurse.
Sentinel Event: The registrar is the first person the family encountered. The registrar
collected the patient’s personal and insurance information. The registrar also had the guardian
sign the Condition of Admission form that allows for billing and treatment. It was determined
that the registrar present during this event, performed the duties as trained and according to NCH
policy.
Pre-Op Nurse
The PO nurse is responsible for preparing patients for their procedure. This includes any
assessments, changing into gowns, medications, IV’s, and obtaining the patient or guardian’s
consent for treatment. In addition, the PO nurse is responsible for explaining to family members
what to expect during surgery. The PO nurse then hands off the patient to the OR nurse.
Sentinel Event: The registrar handed off the patient to the pre-op nurse first. The PO
nurse during this event did the patient’s assessment, prepared her for surgery, medicated the
patient, and informed the mother of the surgery and recovery timetable. It was at this time the
mother informed the PO nurse that she would be leaving and provided the nurse with a phone
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