Sentinel Event
A mother brought her child name Tina to Nightingale Community Hospital for a procedure. The pre‐op nurse informed the mother of the time line for the surgery. The mother had some errand to do involving an older sibling and made the nurse aware of it but would return in time to pick up Tina. To stay informed, the mother gave the pre‐op nurse her cell phone number with instructions just in case Tina got out of surgery sooner than expected. Approximately 2 ½ hours later, the mother returned and her child was already discharge 30 minutes earlier to the child’s father without the mother’s consent to the hospital. At this point, hospital security was called, and hospital‐wide child abduction alert was activated. It is apparent that there is a break down in any process that the hospital may have. Since they were able to release the child to someone that claims to be the father, it is clear that there is a flaw on how the hospital handles this process.
The following personnel were interviewed individually during the sentinel event:
1) Tim Blakely, Officer. At 09:00, Officer Tim received a call and was informed that there was potential child abduction. He immediately went to interview the nurse who stated that a child was missing from the facility for approximately 25 minutes. Office Tim questioned why the call didn’t come earlier and believe that if they performed more drilled, the event could have been prevented.
2) Katie Jessup, Registrar. Patient information was entered in the electronic medical record by Katie.
Since she followed instructions on what to ask and enter on the record, she doesn’t feel like she did anything wrong.
3) Anna Liu‐Dilarno, Chief Nursing Officer. Anna is the Chief of Nursing and is in charge of all the nurses in the hospital. Any events that happen on her watch automatically become her responsibility and she
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