A1: Sentinel Event
Describe the Sentinel Event
On September 14 at 12:30pm, pediatric patient Tina was involved in what was thought to be a child abduction. After arriving at the hospital that morning, Tina’s mother checked Tina in with the registrar. The registrar collected Tina’s demographics and insurance information and entered it into the medical records. She made copies of ID’s and insurance cards and had Tina’s mother sign all necessary paperwork for Tina’s surgery. The registrar did not ask for any information regarding the custody of Tina because it was not a part of her job duties.
Once admitted, the Pre-op nurse greeted Tina and her mother. The Pre-op nurse had Tina’s mother sign all consent forms for the surgery. She then helped Tina get gowned up and began the pre-op assessment on Tina, started her IV and administered her pre-op medications. According to the Pre-op nurse, Tina’s mother did inform her that she’d be doing something with her son during Tina’s surgery. Tina’s mother gave the Pre-op nurse her name and number, which the Pre-op nurse wrote down in her notepad, so she could be called when the surgery was done.
The OR Nurse had very strong feelings on the lack of communication between departments. She said that she has witnessed many issues and seen many problems arise due to a lack of communication and understanding across departments. She strongly believes that working more closely with security would eliminate some of this issues in the future.
Following being prepped, Tina went in for surgery. The surgeon said she did an excellent job. He was upset about the situation with Tina and expressed that this type of negligent behavior could cause legal ramifications for him and the hospital. He did not understand how such a mix up could happen because his office notes clearly state who has legal custody of Tina. He want assurance that his