SENTINEL EVENT This is a case of an inpatient admitted at the Nightingale Community Hospital for a medical procedure which by all standards was a success but the patient is discharged from the hospital without the knowledge of the mother culminating into a sentinel event. Joint Commission (commission, 2013) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury or the risk there of. Serious injury specifically includes loss of limb or function”.
Like in this case, “an event can be considered a sentinel event if the outcome was not death, permanent harm, severe temporary harm and intervention to sustain life”. (commission, 2013).
The required procedure being on appointment, the hospital was prepared for their patient scheduled for Thursday, September 14th at 12:30pm, a three year old Tina Gerhardt admitted to the ambulatory surgery unit (ASU) for bilateral myringotomies (insertion of ear tubes) accompanied by her mother. They were received by the hospital registrar who entered all the required information, processed all the necessary documentation with sign ups and verifications by the mother prior to being forwarded to the pre- op area. They were then received by the Pre-Op Nurse whose main job is to prepare the patient for surgery. In here, all that is necessary was done on Tina while briefing the mother through the entire process and the time each task was estimated to be completed. During the protocol, the mother notified the Pre-Op Nurse of an errand she needed to do with her seven year son but she promise to be back in time to pick the girl and the nurse took her contacts to let her know as soon as the daughter came out of the OR room. It should be noted that the mother opted not to accompany Tina to the door of the OR suite. Tina proceeded to the OR room and after she came out of surgery, the