Sentinel Event Root Cause Analysis

AFT2 Accreditation Audit

October 4th, 2014

Sentinel Event Root Cause Analysis

As defined by the Joint Commission (2014) a sentinel event is, “An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome” (Joint Commission, 2014). The sentinel event concerns a possible child abduction from a surgical unit within the Nightingale Community Hospital (NCH) on September 14th. A 3 year old patient was dropped off with a pre-op nurse for surgery. Prior to this the mother and child complete all necessary paperwork for surgery including appropriate authorization forms. The mother informed the nurse she had to leave the hospital and would return when her child would be released approximately 1 hour and 45 minutes later after the surgery and recovery period. The mother provided contact in case the child was ready for release earlier than the specified time frame. When the child was ready to be released the recovery nurse paged the mother, but the mother had not yet returned. Care of the child was reassigned to the discharge nurse. It was discovered that the father was in the waiting area and was then allowed to see the child. After 30 minutes had lapsed from the time the mother said she would return the discharge nurse elected to provide discharge instructions to the father and released the patient to him. This decision was made because there was not any information in the patient’s file concerning custody of the child or for specific arrangements concerning release. The mother arrived 15 minutes later to pick her child and discovered she had been released to a non-custodial parent and became severely distressed. Local law enforcement