RAFT –Task 2 Root Cause Analysis A-1. Sentinel Event A sentinel event is an event that happens expectantly in a healthcare facility that could result possible death, physical or mental injury to patients unrelated to natural causes of the patients illness as defined by Joint Commission (www.joint commission.org). On the afternoon of Thursday, September 14, at approximately 12:30 p.m. a ‘Code Pink’ (child abduction alert) was called when a minor child/patient, Tina, was discharged to the care of her father without the knowledge of her mother with whom she was admitted with. Tina was registered into the hospital system by Katie Jessup, hospital registrar, who entered all proper demographics and all proper insurance information into the system. The mother was given a time given an estimated time of discharge to be one hour and 45 minutes by the Pre-op Nurse, Greta Doppke. The mother informed Nurse Dopke that she had to leave the hospital to run an errand and specifically gave her cell phone and instructions to call if Tina were to be released earlier than the time specified. Tina’s mother’s errands ran over 2 1/2 hours, which is 45 minutes later than estimated time and the young patient grew restless. Crying for her mother the discharged nurse, Kim Johnson got word from security officer Tim Blackely that Tina’s father had arrived and was in in the main reception area. Nurse Johnson, upon recognition from the child, allowed the father to visit his daughter. Thirty minutes had gone by and the mother still hadn’t returned. Nurse Johnson then released patient Tina into the custody of the father. Fifteen more minutes passes when Tina’s mother arrived back at the hospital to learn that Tina had been discharged. Security was not called until another 25 minutes according to security officer Tim Blackely when the ‘Code Pink’ was activated. Local police were also involved. Upon