On Thursday September 14th at around 12:30 pm the hospital had a sentinel event which involved a missing child. The event details are as follows: Tina was scheduled for same day surgery and was brought to the hospital by her Mother. Her Mother was informed that the surgery would take approximately 45 minutes and that Tina would be in recovery at least 1 hour. Tina’s Mother informed the pre-op nurse that she had an errand to run involving Tina’s older sibling. Tina’s mother left the pre-op nurse her cell phone number with instructions to call her if Tina got out of surgery and was ready to go before she returned.
Prior to Tina’s mother returning Tina’s father showed up to check on her, and finding that she was ready to go he took her to his house until the mother could pick her up. When Tina’s mother returned 2 ? hours later she found Tina missing and the staff did not know that her father took her. The hospital activated a Code Pink and notified the local police department. When the hospital security interview the mother they learned the parents were divorced and that she had full custody of Tina and her other siblings.
The local police found Tina at her father’s home within 30 minutes of Tina’s mother returning to the hospital. No charges were filed against the father. There were eight main employees that interactive with Tina, her mother and father in the sentinel event. We will be looking at each of their roles in the order that Tina and her parents interacted with them: Katie Jessup is the registrar that admitted Tina to the hospital. She asked the standard questions, made copies of the insurance information and recorded it all into the computer system for admission and billing.
As she was trained she did not ask any questions that were not on the standard questionnaire form that all patients fill out. Greta Doppke is the pre-op nurse who took Tina and her mother back to prepare for her surgery. Greta completed her nursing pre-op nursing assessment, started her IV, administrated her pre-op surgery medications and documented it all on the administration documentation records. Greta had Tina’s mother sign the consent form for the surgery and made a note in her note book of the mothers name and cell phone number because she wanted to be notified when Tina came out of surgery.
Greta then took Tina over to the surgical suit and handed her of to Rosemary Fry the O. R. Nurse. Rosemary Fry is the O. R. Nurse that received the patient from Greta. She took Tina into surgery and had no interaction with Tina’s mother, was not informed about calling her after the surgery and worked with Dr. Munoz for the procedure. Dr. Carlos Munoz was the surgeon on this case. He claims that in his patient notes that he states how the custodial parent. He also claims that the Hospital staff never request his patient notes.
Jon Peters is the recovery room nurse, he took report from Rosemary. He over saw Tina’s post recovery. When Tina was ready to be discharged he called out to the waiting room and also paged Tina’s mother. When she did not respond He Tina to Kim the discharge nurse Kim Johnson is the discharge nurse that took Tina and report from Jon Peters. Jon notified Kim that he was unable to find Tina’s mother. Tina started to cry and be very un- happy. Kim found out that Tina’s father was at the front desk so Kim invited him back. Tina recognized him and called him father so Kim knew that he was Tina’s father.
After they had been waiting for 30 minutes Tina’s father suggested that he could take Tina to his home until the mother could come and get her. Kim agreed that that would be a good idea and had him sign Tina out and sent her home with him. Tim Blakely was the security guard that was called when Tina was found missing. Tim was notified 25 minutes after Tina was missing. Tim went to the discharge area and interviewed the nursing staff. Anna Lin-Dilarina is the Chief Nursing Officer, she was not involved in the Tina incident but wants be involved in making sure this does not happen again.
While reviewing the interviews I discovered that all of the staff and department were very quick to point their finger at the others. This is going to be the biggest hurtle that will need to be addressed before we can look at correcting this problem or any others that may concern multi departments. It can be summed up that the root cause of this problem is a lack of communication and procedures with an underlining concern that the employees do not feel like they have job security. The problem that occurred with Tina is the result of these bigger issues 1.
A straight forward policy on dealing with minors, parental custody and safety. In the case of Tina several of the departments and employees showed skill in gathering the appropriate information they just did not know what to do with that information because they were short staffed and did not have the time for a personal one on one meeting with the nurse taking Tina. 2. Improved communications from the admissions office, doctors’ offices and hospital medical departments. A common theme while reviewing the interviews was that they did their job it was somebody else that dropped the ball.
This comes from only doing their job and not thinking beyond that. 3. Having properly staffed units. It was also mentioned that several of the departments were short staffed and this makes it hard to do more than just your job. It leaves little to no time for the extras like making sure all the notes are properly passed on the new staff. 4. The underlying problem that nobody said but was felt is that nobody feels like they have job security. It only will take one mess up and they will be fired and or replaced.
This mentality weather correct or not breeds I better watch my back and only my back because nobody else will. It also does not encourage employees to do more than their jobs. The quality method needs to insure an increased level of communication between departments. This communications needs to be policy based as well as concern for patient care. The root cause of this sentinel event comes from a lack of communication. The improvement method used is the FADE method: which stands for: Focus – Look at what is really this issue or issues Analyze – Review the data to determine the root cause or possible solutions.
Develop – Put together a plan it improve or correct the root cause, implementation, communications and a form of monitoring the plan Execute – Put the plan into action and evaluate its ongoing progress This is the basic for putting together the corrective plans (Methods of quality, 2005). There are several things that need to be addressed to help improve the patient care, nursing staff issues and reduce the risk of having problems in the future. I would recommend implementing the following: 1. Start a cross training program for the nursing staff.
This will provide several benefits. I first and for most will help with the staffing needs, there are always nurses looking to pick up additional shifts that cant because of training issues. It will also improve communication and department relationships. And will be a valuable tool in determining who is qualified for promotions. It will allow nursing staff to be evaluated by several departments along with helping the nurses show the hospital that they are teachable and willing to learn. 2. Re-designed patient forms. These new forms need to start with the admissions paper work.
It needs to include contact information, guardianship information and any special concerns or issues the patient or legal guardian might bring up. These forms also need to include additional space for more in-depth nursing, staffing and doctors notes. This would allow the staff to better communicate with each other when time is limited. 3. Implement staff suggestion boxes. These boxes are not to complete boxes but suggestion boxes with ways to implement them. These suggestions will be review and the employee who made the suggestion will be given the opportunity to explain why this change would be a good improvement.
On the suggestions that have merit and are going to be implemented the employee will be give the opportunity to be lead on the change. They will also be reward for implemented suggestions. This will help get the employees involved in making improvements to their departments; improve working conditions and patient care. The D. O. N and Department heads need to start to implement a cross training program. This can be accomplished by selecting one or two staff members along with the department heads to have staff from other departments shadow them and start the training process.
When the selected staff feel like they are ready to work on their own the department head can shadow them and sign off on their skills and authorize them to work in that department. Once they are signed off they can be added to the call list to help pick up when staffing is needed. The Administration needs to work the D. O. N. and department heads to determine what changes need to be made to the current forms. They also need to work with the admissions department on what their needs are. When this information has been gathered they need to meet with the I.
T. and design departments to put together new sample forms and software changes for the final approval of the Administration and Departments. This process needs to be followed until the final project meets everybody’s needs. Then they can be produced and implemented. This implementation will take place in the department monthly in-service meetings. The department heads need to review the suggestions on a weekly bases. They need to take the suggestions and talk with the employee that made it to get a feel for what they are looking to change and how.
The department head will also be a resource for the employee to get their suggestions written up into a true proposal. This proposal can then be presented to the D. O. N. and administration for review and possible implication. This will also help with employee morale and help them feel they are an important part of the hospital and valued. It will also improve communication between staff and administration. These are the steps that need to be implemented to start to help the hospital avoid future problems while correct the problems at their root not just putting out the fires as they occur.
? References Analysis of key components. In (2012). Nightingale Memorial Hospital Blakely , T. (2012, September 14). Security [Personal Interview]. Sentinel event interview. Doppke, G. (2012, September 14). [Personal Interview]. Pre-O. P. Nurser Sentinel event interview Fry, R. (2012, September 14). [Personal Interview]. O. R. Nurse Sentinel event interview. Jessup, K. (2012, September 14). Registrar [Personal Interview]. Sentinel event interview. Johnson, K. (2012, September 14). [Personal Interview]. Discharge Nurse Sentinel event interview. Liu-Dilaarno, A. (2012, September 14).
C. N. O. [Personal Interview]. Sentinel event interview. Methods of quality improvement In (2005). Patient Safty – Quality Improvement Duke University Medical Department. Retrieved from http://patientsafetyed. duhs. duke. edu/module_a/methods/methods. html Munoz, C. (2012, September 14). [Personal Interview]. Surgeon Sentinel event interview. Peters, J. (2012, September 14). [Personal Interview]. Recovery Nurse Sentinel event interview. Sentinel event report. In (2012). Nightingale Memorial Hospital Sentinel event action plan – oig guidelines. In (2012). Nightingale Memorial Hospital.