Nightingale Community Hospital: Sentinel Event

Registrar, registered child (3 year old patient), obtained insurance card and entered demographics. She was then taken to pre-op where the nurse told mother that once in the OR the surgery would take about 45 minutes and then she would go to recovery. The mother informed the pre-op nurse that once her daughter went into the O. R. she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number phone number with instructions to contact her if her daughter got out of surgery sooner than expected.

The Pre-op nurse wrote her number down on her note pad that she carries around in her pocket. The daughter was taken into surgery by the O. R. nurse nothing was mentioned about the mothers’ phone number or contact instructions to the O. R. nurse. After surgery the daughter was taken to recovery where the recovery nurse took care of the patient until she was ready to go to the discharge ambulatory care. The recovery nurse paged the patients’ mother when she was coming out of anesthesia, but could not locate her. The recovery nurse kept her until ready to go to the ambulatory care for discharge.

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Security had called and said the father was at the main reception to come visit the daughter. The discharge nurse also tried to page mother, who still was not available. The patient was crying and wanted to go home. The discharge nurse let the father back to see the daughter. After 30 minutes had passed and mother was still not present, the father offered to take the patient, home with him. Since the patient called him daddy and was excited to see him, discharge nurse thought it was ok to send her home with her father. The discharge nurse had him sign all pertinent paperwork sent her home with him.

The mother returned 2 ? hours later and found that the daughter was discharged 30 minutes earlier. Mother was extremely distraught and security was called and a “Code Pink” (hospital-wide child abduction alert) was activated. Local law enforcement was also contacted by hospital security. When security officer interviewed mother, she shared with him that she and patients father were divorced and that she had full custody of daughter and her siblings. The Daughter was located within 30 minutes of her mother’s arrival by local law enforcement, in the care of her father.

He had taken her to his home to await the arrival of the mother. If the Pre-Op nurse would have passed on the mother’s phone number where she could be reached and noted that she was on an errand with sibling, a lot of the events could have been avoided. Roles of Personnel Present Surgeon Supervises the actions of the surgical team, orchestrating their responsibilities and generally responsible for the outcome of the surgery. Chief Nursing Officer Responsible for overseeing and coordinating an organizations’ nursing department and its daily operations.

Works to align the nursing staff with the mission, values and vision of the organization. Pre-Op Nurse Bring patient back, Changes her into hospital gown, confirms hours with post-op nurse, confirms patient has a ride home (name and phone number in chart), Witnesses signing of the O. R. consent, and they have a basic understanding of what the surgeon is going to do. Mark side of surgery will be on, Starts their IV, check surgeons orders or per protocol, put on antibiotics, shave or prep area. Check all paperwork. Check to see if there is the surgeons’ history and physical within 30 days.

Is there lab work or EKG’s (if needed)? Recovery Nurse Provides constant care to patients immediately following surgery; anywhere from 30 minutes to a few hours until patient is stable enough to be transported to a hospital room or discharged from the facility. Connects patient to cardiac monitoring equipment, and intravenous therapy for fluids and pain medication. Pain intervention-assesses pain levels, makes complete notes on charts, communicates to the PACU nurse & physician. Completes any forms required by facility. Makes patient observation, Takes patients vital signs (blood pressure, pulse and temperature).

Ensures patient is breathing properly, and administers oxygen when needed. Must be able to react to signs of negative change, call for assistance and begin CPR if necessary. Discharge Nurse Review surgeons written discharge instructions. Goes over discharge with patient. Has patient sign discharge instructions Hospital Security Guard Will ensure the safety of the hospital premises. Helps in evacuation drives in times of fire and threats. Interacts with hospital staff of all departments with special emphasis on drug storage areas, infant care units, and ward for mentally ill patients and trauma care.

Personnel Issues The Hospital environment can offer some practical challenges that could be barriers in communications. Many patients have individual needs and this can impede on a nurses time and emotions. Nurses put in long hours and have a high patient/nurse ratio or shortage of healthcare workers. Nurses/personnel have to deal with emergencies in an already challenging and busy hospital setting. Dealing with patients takes mental acuity and emotional support and sensitivity. Hospital guidelines might not have sufficient communication practices among personnel in place.

Improving Interactions In order to improve interaction amongst personnel there needs to be a constant. That constant needs to be the patients chart following the patient, where hand offs notes from one staff to the next can be kept updated at all times when medications is administered and also when the patient has been checked in and phone numbers can be quickly accessed after surgery and in an emergency to reach the Responsible party that brought the patient in whether it be a friend or parent.

Phone numbers and notes involving a minor child, needs to be highlighted in each handoff so the personnel receiving knows there is notes of importance being handed off and read from one department to the next so they know who to reach, and can be quickly reached without having to search in files. When involving a minor child, custody and phone number needs to be consistent on handoff notes from one personnel to another. Risk Management The quality improvement than need to take place in Nightingale regarding a minor, needs to begin at Admission/Registration.

All patients admitted requite a bracelet with name of patient, attending doctor and an ID number. In the case of a minor child, the adult admitting will be given an identical bracelet. Upon discharge, the caregiver must match the Childs’ bracelet with the parent/guardian. Without the identical bracelet, child will not be released to anyone until an investigation has been performed through security that child is being released to the rightful parent/guardian. A new risk management program will be put in place requiring all relevant personnel to attend the workshop in orders to update security issues.

These issues will require all floor personnel to attend. All personnel will also be required to call security, immediately upon knowledge of a patient missing or child abduction. Quality Improvement The aim is to improve security measures in the hospital. ·The hospital will improve security by requiring all patients to have a patient I D Bracelet and the parent admitting any minor to also have one. Upon discharge Minor patient and Responsible Adult must have matching ID Bracelet before being released from hospital. ·Security is to be called immediately on any issues that pertain to the safety and wellbeing of any patient and/or the facility.

·Hire Hospital Security Consulting Service to consult on present security issues and any additional needed improvements. The System will relate to: Improving Patient Safety Measurement The measurement will be to Plot Data for measures. The new measures will be over time, using a run chart to determine whether changes are leading to Improvement. The change will be implemented by a team, to ensure new safety issues are carried out. That team will consist of: ·Clinical Leader:- MD , Patient Safety Officer ·Technical Expert:- Quality Control Expert Consultant·

Day-to-Day Leadership: RN, Manager, Medical/Surgical Nursing ·Additional Team Members: Risk Manager, Quality Improvement Specialist, Staff Nurse, Staff Education, and Information Technology. ·Sponsor: MD, Chief Medical Officer The team includes members familiar with all aspects of the process, from managers, Administration to Physicians and nurses and front-line workers. The Executive Sponsor will be responsible for the success of the project The Clinical Leader: has the authority to test and implement change that has been suggested and deal with any issues that arise.

Understands clinical implications and consequences. Technical Expert: Knows the subject intimately. An expert on improvement method. Helps the team in determining the measurement method, design of interpretation, and display of data. Day-to-Day Leadership: Will be the driver of the project, insuring tests are implemented and data is collected. Project Sponsor/Executive Sponsor: the executive liaison with executive authority who serves as the link to senior management and the strategic aim of the organization.

Can provide resources and overcome barriers and provide accountability for the teams progress on a regular basis but not day-to-day. Langley, Nolan, Norman, Provost, The Improvement Guide 2009 Security Issue Resource Nightingale Hospital will hire an expert, Hospital Security Consulting Service to assess the security the hospital has in place and how it can better implement its security issues regarding the recent sentinel event and any other issues needed to keep current for Joint Commission Standards.

This consulting firm will also provide the risk management workshop to all employees in regard to patient care personnel security issues, to support the new changes. All employees, hospital-wide, will be updated to all quality improvements and risk management guidelines. References JCI Accreditation Standards for Hospitals, 4th edition (e-book); July 2010 Philip Stahel; Patient Safety Surgery Journal, 2009, 3:14 Langley G. L. , Nolan K M, Norman C L, Provost LP The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition) San Francisco: Jossey-Bass Publishing; 2009.

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