AFT2 Task 2
WGU
Sentinel Event Description
A minor child was brought in to the OR for surgery. The surgery would take about 45 minutes, and then she would spend an hour in recovery. The mother informed that pre-op nurse that she needed to run an errand for her other child but would be back befor...
A minor child was brought in to the OR for surgery. The surgery would take about 45
minutes, and then she would spend an hour in recovery. The mother informed that pre-op nurse
that she needed to run an errand for her other child but would be back before the minor was
ready to be discharged. She gave the pre-op nurse her cell phone number and asked that she be
notified if her daughter got out of surgery sooner than expected.
The mother returned at the time agreed upon, but her daughter was discharged 30 minutes
earlier. She was extremely distraught, and security calls a “Code Pink” (hospital-wide child
abduction alert and law enforcement was contacted. When law enforcement interviewed the
mother, she informed them she is divorced from the father, and she has full custody of all of the
children.
The child was located within 30 minutes at her father’s home. No charges were filed
against the father, and the mother was reassured that the incident would be investigated and
processes implemented to prevent an event like this from recurring.
Personnel Roles and Responsibilities
Chief Nursing Officer
, ` The Chief Nursing Officer was not directly involved in the sentinel event but is
responsible for the nurses involved in the event. She is ultimately responsible for the workflows
the nurses follow while on duty.
Registrar
The registrar is directly involved in the sentinel event. The registrar must obtain
and enter accurate demographics of the patient. Demographics include insurance information,
address, phone numbers, and responsible party and to obtain consent for treatment. Custody of
the minor child was not questioned or entered because it is not the current workflow to do so.
Pre-Op Nurse
The pre-op nurse is directly involved in the sentinel event. The responsibilities of
the pre-op nurse include obtaining informed consent from the patient or guardian, starting the IV
and administering pre-procedure medications, documenting in the patient's electronic medical
record, and making sure the patient changes into the appropriate gown. The role that the pre-op
nurse played in the sentinel event was she took the information from the minor child’s mother
that she had to leave and would return at the instructed time. The mother also requested that if
her child discharged any earlier to call her and provided her with the cell phone number. Custody
arrangements were not discussed. The information was documented in the nurse’s notepad but
was not entered into the patient’s chart. Once the pre-op nurse’s duties were complete, care of
the patient was transferred to the OR nurse.
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