AFT Task 2

A1. Sentinel Event The Joint Commission’s definition of a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (http://www.jointcommission.org). The Joint Commission list specific events that are considered reviewable. One of those events is the abduction of a patient
On Thursday, September 24th, at approximately 12:30 p. m., a mother arrived to pick up her daughter from the hospital’s outpatient surgery department. The mother left 2 ½ hours earlier to run an errand. When the mother arrived, she was told that the child had been discharged. The child’s mother and father are divorced, and the mother has sole custody of the child. A “code pink” child abduction was called, and local law enforcement notified. The child was found unharmed thirty minutes later at the home of the child’s father.
The mother brought the child to the hospital for outpatient surgery that was to take approximately 45 minutes with a period of recovery of one hour. The mother requested that the nurse call her on her phone should the child get out of surgery early, and she left her cell phone number with the nurse. After the mother left, the father came to visit the child. The nurse stated that the child was upset, but when she saw her father, she calmed down so the nurse gave the father the discharge instructions and discharged the child to his care.
No charges were filed against the father, however, the CEO of Nightingale Community Hospital assured the mother that there would be a full investigation into the incident, and an action plan developed and implemented that would