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Accreditation Audit: AFT2 Task 2

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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Analysis of Key Components RCA: Child Abduction Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated.

Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-­‐year-­‐old female pediatric patient who was under went her pre-­‐operative assessment as an outpatient at her Ear, Nose and Throat (ENT) surgeon’s office. On the day of surgery, the patient and her custodial parent, the mother, presented to the ambulatory surgery center as scheduled. Once at the hospital, the patient and her custodial parent went to the registrar and completed the necessary routine paperwork. No questions were ask or required as to who the custodial parent was or who was authorized to assume custody of the child at time of discharge. The patient and custodial parent, the mother,next met by the pre-­‐operative nurse and taken to the pre-­‐operative holding area. The nurse then completed all required paperwork, assessments, pre-­‐operative tasks and medications. At this time, the mother informed the nurse that she would be leaving the hospital temporarily but left her contact information including her cell phone number and requested to be called on that number when her daughter was out of surgery. There was not any discussion as to who the custodial parents were or who was authorized to accept custody at time of discharge. There does not appear to have the contact information or mother’s request to be called at time of discharge transferred to operating room nurse. Once the pre-­‐operative work was completed, the operating room nurse took the patient to the operating room and the mother left the hospital. There does not appear to have been any contact between the operating room nurse and the mother. There does not appear to be any information transfer between the pre-­‐operative nurse and the operating room nurse. Following the surgery, the patient was transferred to the recovery room where the child did well. The operating room nurse and recovery room nurse did not transfer any information regarding who the custodial parent was or the mother’s contact information and request to be notified by cell phone. The recovery room nurse did attempt to contact the mother via the hospital paging system in the recovery room without success. No further attempts were mad by the recovery room nurse.

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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When the patient was fully recovered and ready for discharge home, the patient was transferred to the discharge nurse. The only information that was transferred between nursed regarding the patients discharge was that the mother was unable to be contacted in waiting area. No further attempts to contact the mother are identified. The father presented to the recovery room waiting area and was brought back to the patient. After 30 more minutes the father offered to take the daughter home. No questions regarding the custodial rights were asked. The patient was discharged into the fathers care. The mother returned to the hospital 30 minutes later only to discover her daughter had been discharged to the father, her ex-­‐husband. She was very distraught. After another 25 minutes the nursing staff notify security that immediately contact the local law enforcement. The child is found in good spirits without harm at the fathers house. Although the event should not have happened and caused a lot of undue stress on the mother, the out come of the patient was without harm.

Who participated in the analysis? Please include a list of all team members that participated in the analysis by position and title. Please DO NOT include any names!

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Surgeon Chief of Staff Security Administration: Chief Nursing Officer (CNO) Registrar Pre-­‐Op Nurse O.R. Nurse Recovery Nurse Discharge Nurse Quality and Risk management Director of Nursing for Surgical/Ambulatory surgery department

When did the event occur? Include the date and time the event took place.

 September 14, Thursday at 12:30pm

What area/service was impacted?      Nursing service Registration service Security service Communications service Patient relations service

What are the steps in the process, as designed? (Flow Diagram(s))

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The organization may provide a Flow Diagram(s) of the steps in the process involving the occurrence. The organization may also list the key steps involved in the specific processes relating to the event. Ask-­‐-­‐are all issues in the flow addressed? Suggestions are outlined below.

This is how the process currently works.

Parent Registers Child

Parent and Child taken to pre-­‐op areas by RN and prepared for surgery (pre-­‐op assessment done and consent signed) Parent can accompany child to door of OR suite

Post op, child transferred to recovery area

Once stabilized, parent and child reunited

Discharge teaching done and child discharged with parents once recovered

What human factors were relevant to the event? Evaluate the role of human performance factors that may have contributed to an error.

 Failure to share important out patient office documents with relevant information  Failure to ask pertinent information at time of admission, during stay and at time of discharge  Failure to communicate pertinent information from staff to staff and department

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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to department  Failure and/or delayed notification of security breech

How could equipment performance affect the outcome? List the various equipment utilized for that patient during the healthcare stay. To assist in evaluating these processes consider the following: Were bio-­‐med checks done and up-­‐to-­‐ date? Was the equipment where it was supposed to be? Why or why not? Was staff in-­‐ serviced on equipment? How long ago? How frequently is the equipment used? Were alarms, displays, and controls identifiable and/or operating properly? Is the equipment set up and performing in accordance with the manufacturer’s recommendations? Were there equipment recalls that were not addressed? Was equipment designed to accomplish its intended purpose? Were equipment parts defective? Was there a report to another agency regarding equipment defect (FDA, etc)?

 No equipment issues were involved in this event.

What controllable factors directly affected the outcome? Identify factors that may have contributed to the event that the organization has the ability to change by making process improvement changes.

 Failure to properly identify child’s legal guardians  Failure to document guardian’s contact information  Failure to properly notify security in a timely manner  Failure of communication between staff and departments

Where there uncontrollable external factors? Uncontrollable external factors are those factors that the organization cannot change that contribute to a breakdown in internal processes. An organization should not be willing to assign many issues to this category. Although a factor may be beyond the organization’s control, the organization may be able to minimize the factor’s effect on patients.

 Father coming to see daughter (not under organization’s control)

What other areas or services are impacted? List all other areas that have the potential for a similar event to occur. This will assist in implementing risk reduction strategies in other pertinent high-­‐risk areas.

 Inpatient units

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 Any ancillary/clinical department that may separate parent from pediatric patient

To what degree is staff properly qualified and currently competent for their responsibilities? Include all staff present, not just those that were determined to be involved with the event. Do not overlook physicians and allied health practitioners/mid-­‐levels. Determine if staff was formally trained to perform the specific duties or tasks involved in the event. Was the training adequate? Was staff qualified to use the equipment? Were competencies documented? Had procedures and equipment been reviewed to ensure a good match between people and tasks performed? Was there agency staff that may not have been familiar with procedures/equipment? Was float staff from another area assisting with lack of orientation to the unit they floated to? Was the individual new and performing a function that they were not oriented/trained/competent in performing? Was staff oriented to the organization and department specific policies/procedures?

How did actual staffing compare with ideal levels?

 No process in place at the time of incident to provide guidance to staff to directly prevent such an incident  Staff had been appropriately oriented to the department/organization and did not have any performance issues.

Was there appropriate staffing at the time of the event to address the required workload? Keep in mind if it was a weekend, change of shift, holiday, break time. Document the actual staffing in area of occurrence versus planned staffing according to the staffing model. Explain any variation; higher or lower staffing.

 Pre-­‐op: Staffing model requires four RNs and one unit secretary that is shared with post-­‐op side. Actual staffing was three RNs which resulted in pre-­‐op nurses prepping additional patients than usual.  Post-­‐op: Staffing model requires four RNs with the shared unit secretary. Actual staffing was three RNs.

What are the plans for dealing with contingencies what would reduce effective staffing levels?

Summarize current plans in place to deal with staffing deficiencies.

How has staff performance in the relevant processes been assessed?

 Plans are in place to use float pool nurses, contact part-­‐time staff for extra hours, or reassign staff from other units.

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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When was this last performed? Consider staff performance relative to the specific processes associated with the event.

How can orientation and in-­‐service training be improved?

 NA—No process in place at the time of incident to provide guidance to staff to directly prevent such an incident

Was all staff oriented to the job responsibilities, organization, and policies and procedures regarding safety, security, hazardous materials, emergency, equipment, life-­‐safety, treatments, and procedures? Are policies revised/updated, evidence based, and readily available? Have policies or procedures changed without providing additional training? Was a new policy developed and staff training conducted? Do float staff or agency staff receive training within the areas they are assigned? Is this documented?

 At time of hire, yearly or at time of accepting appropriate responsibilities: in-­‐ service training appropriate for position will be required prior to filling the position  Written policy requiring registration, nursing staff involved in direct patient care and discharge nursing staff associated with pediatric patients to question and document who is the legal guardian and who is authorized to sign the pediatric patient out of the hospital at time of discharge  Written policy requiring immediate security notification when child abduction is suspected  Written policy to implement existing policy on new born unit hospital wide  Written Policy for all Departments to routinely check who is authorized as accepting guardian prior to release of pediatric patient from their department to non-­‐hospital staff  Written policy for all out patient prepared elective procedure to have the complete history and physical placed on the chart and for pediatric patients a specific statement as to who is the legal guardian  Written policy for all staff transferring care of patient to give an in depth verbal and or written summery of patients status and in the case of a pediatric patient must include who the legal guardian is, who is authorized to accept the patient at time of discharge and appropriate contact information  Routinely scheduled “code pink” drills hospital wide  Consult information technology department to assist with the insertion of the

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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legal guardianship and authorized family/friends who can accept a pediatric patient from hospital at the time of discharge  Contact the supplier to order patient specific wristbands that will match I.D. numbers on pediatric patients and legal guardian. Have legal guardian name on I.D. band. Have contact number and alternative number present.

To what degree is all information available when needed? Was information from various patient assessments completed, shared, and accessed by members of the treatment team as required by policy? Was the patient correctly identified? Was the documentation clear and did it provide an adequate summary of the patient’s condition, treatment, and response to treatment?

Was the level of automation appropriate? Identify what information systems were utilized during patient care.

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Information from the surgeons office was adequately collected but not shared with the out patient surgical staff: Policy to be made requiring all pre-­‐operative or pre-­‐admission charts to be transferred to appropriate unit within 24 hours of patient admission Registration information not adequate during assessment: information technology (IT) to be tasked with up dating computer registration information for pediatrics to include who are the custodial parents and who is authorized to assume care of the child at time of discharge. Nursing communication broken down. Pre-­‐op nurse obtained critical information but failed to chart the information appropriately or communicate it effectively during patient “hand-­‐off” to fellow nurses: Policy to be made and implemented requiring information collected to be placed in patient’s chart. Policy to be made requiring nurse-­‐to-­‐nurse verbal and written patient summary at time of hand-­‐off; in pediatric patients must include who is the custodial parents or legal guardians and contact information. “Code Pink” is available but not hospital wide: Continue “code pink” drills on current units as planned. Expand “code pink” drills quarterly in various units throughout the hospital.

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To what degree is communication among participants adequate? Look at this content to cover verbal and lack of verbal/written communication(s)

 Physician to ambulatory surgery department: inadequate written and/or verbal communication.

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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To what degree was the physical environment appropriate for the processes being carried out?

Physician to nurse: inadequate written and/or verbal communication. Nurse to Nurse: inadequate written and/or verbal communication Registration to patient/family: inadequate written and/or verbal communication Nurse to security: delayed communication

Look closely at the environment the patient was in or was transferred to/from. Spaces, privacy, safety, and ease of access are a few items to consider. Was work performed under adverse conditions (hot, humid, improper lighting, cramped, noise, construction projects)? Had there been environmental risk assessments conducted? Did the work environment meet current codes, specifications, and regulations? Was the work environment appropriate to support the function it was being used for?

What emergency and failure mode responses have been planned and tested? Had appropriate safety evaluations and disaster drills been conducted? Had provisions been planned and available to support a breakdown in operations?

 NA—Physical environment did not play role in incident

To what degree is the culture conducive to risk identification and reduction? Did the overall culture of the facility encourage or welcome change, suggestions, and warnings from staff regarding risky situations or problematic areas? Does management establish methods to identify areas of risk or access employee suggestions for change? Are changes implemented in a timely manner?

 “Code Pink” drills are done sporadically and not on routine basis

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

 A member of the Senior Leadership group, including the CEO, participates in meetings related to serious adverse events.

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 Senior Leadership and department management encourage staff to bring

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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What are the barriers to communication of potential risk factors?

 Senior leadership and department management all are active in patient safety rounds and encourage open discussion of patient safety issues among staff.

opportunities and suggestions forward that would improve patient care and the work environment.

What is your organization doing to break down barriers to effect change? Has the organization identified barriers to effective communication among caregivers? If there are no barriers, what have you done and how do you know it has been successful? Be specific.

 Information Technology: inadequate information obtained during registration of pediatric patients. Computer to be up dated. All pediatric patient intake information will require custodial parent information and who is authorized to sign the patient out at time of discharge.  Registration: up to date computer information to require the input of information of who are the custodial parents and who is authorized to pick up the pediatric patients at the time of discharge.

Policy made to require registration clerks to clearly document on the chart who are the custodial parents and who is authorized to sign pediatric patients out at time of discharge.  Nursing: Policy made to require nurses during “hand-­‐off” communication to provide a brief written and verbal summery of the patient which is to include in the pediatric patient the name of the custodial parent, contact information and who is authorized to sign the patient out at time of discharge.  Identification: Al pediatric patients and custodial parents are to have wrist bands placed at time of registration with matching identification numbers and the name of custodial parent or those authorized to pick the patient up at the time of discharge.

To what degree is the prevention of adverse outcomes communicated as a high priority? Explain leadership’s role and how it is put into practice, provide examples.

 A confidential suggestion box and hotline have been established to report high-­‐risk issues and each of these are read and evaluated by the Patient Safety Officer. Corrective actions are taken on a regular basis.  “Patient Safety” is one of the organization’s values.

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

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Was there a literature search done? List all sources of literature accessed to complete the analysis and action plan. Literature may be accessed to assist in analyzing the event to determine process breakdowns and/or when developing actions once the root causes have been identified to assist in developing best practice recommendations for changing current practice.

 NA

Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.