Root Cause Analysis
A.1 Sentinel Event Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact information from the mother who notified staff she would be leaving the hospital during the surgery to attend to a sibling matter at home. The mother left her cell phone number as the best contact number to call. This number was entered into the nurse’s personal notebook but was not entered into the patients chart. Post-surgery, the child was taken to the recovery area. The mother had not yet returned to the hospital. During the recovery period the child became more anxious without her mother at bedside. A male presented to the recovery area and identified himself as the child’s father. The patient identified the male as “daddy” and appeared to be comforted by his arrival. The father was provided discharge instructions by the post-operative nurse and was released to his care. Approximately 2 ½ hours later the mother arrived at the unit and was notified the patient had been discharged to home with her father. Mother became very upset, stating the she and the father were divorced and she was the custodial parent. At this point security was notified and a “code pink” was activated. Local law enforcement were also notified by