WGU Accreditation Audit RAFT Task 2: Root Cause Analysis of a sentinel event A Root Cause Analysis (RCA) of a sentinel event is completed to immediately investigate and respond to possible inductions involving the death or injury of a patient. (Joint commission, 2013). Purpose of this report - To execute a Root Cause Analysis for a Sentinel Event occurrence at Nightingale Hospital. Sentinel Event - Child Abduction Date of Issue/Incident – Thursday September 14, at 12:30 PM Background of Issue/Incident - A three year old female patient was brought to Nightingale Hospital by her mother for an outpatient surgical procedure. The mother asked the pre-op nurse how long the procedure would take, because she had to tend to another child and would need to leave for a short while.
Running head: SENTINEL EVENT ROOT CAUSE ANALYSIS 1 Sentinel Event Root Cause Analysis Kalleen Campbell Accreditation Audit Task 2 April 20, 2013 SENTINEL EVENT ROOT CAUSE ANALYSIS 2 SENTINEL EVENT ROOT CAUSE ANALYSIS 1. Identification of Process This report was received regarding an event that requires investigation: The pre-op nurse told the mother that once Tina went to the OR, her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour. The mother told the nurse that once Tina went to the OR, 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 with instructions to contact her if Tina got out of surgery sooner than expected. Tina’s mother returned to pick her approximately 2 ½ hours later and found that Tina was discharged 30 minutes earlier.
The Joint Commission list specific events that are considered reviewable. One of those events is the abduction of a patient On Thursday, September 24th, at approximately 12:30 p. m., a mother arrived to pick up her daughter from the hospital’s outpatient surgery department. The mother left 2 ½ hours earlier to run an errand. When the mother arrived, she was told that the child had been discharged. The child’s mother and father are divorced, and the mother has sole custody of the child.
Has Marianne ever discussed end of life care or issues with her husband and children? What percentage of quality of life does the Physician think Marianne will have post-surgery? Marianne’s husband should be informed and made to understand that her brain is not functioning, she is unable to breathe on her own and she may never be able to do so again. The care team must explain to the family if there are any other options she may have available at the state of her well-being. Information should be thoroughly given to the family pertaining to what her quality of life will be pre and post-surgery.
They spent a good amount in the store but it was just because they weren’t prepared. A few weeks after, Meredith was rushed to the hospital to give birth to her 8 pounds 7 oz. baby boy named Luke. A month later she had to attend the physician’s office to make sure everything was doing well with her and her infant. A couple of months after she realized her child had no toys to play with so she took him to the toy company to pick out a few toys, and ended up getting a ton!
The patient made it very clear that she did not want the phlebotomist to draw her blood (Finnegan, 2013).This same phlebotomist has drawn her for several days for a Prothrombin Time (PT) and Activated Thromboplastic Time (aPTT) without incident, so he reports this situation to the nurse. The nurse informs the phlebotomist that the patient has formed a complaint against him and did not want him, in particular, to draw her blood. The blood had been drawn from the dorsal side of her hand for several days, which was now bruised and swollen. The patient complained of moderate pain, especially when she moved her fingers. Upon observation there was a diffuse ecchymosis over the dorsal side of the hand that extends up the forearm to the elbow.
10/10/13 Nicole Malpica American Government Marcucci 5 Period In pain, a girl waits for government to open Because of the government shutdown, Justin Smith fears his daughter, McKenna, will not get the treatment that she needs. She has a rare genetic disorder called Neurofibromatosis. After days of not hearing from the doctors, he grew upset and tweeted “governmentshutdown needs 2 end now; have the House come here to apologize to my young daughter and others.” Then after five months of waiting, Smith received a call from National Institutes of Health calling to say that his daughter got into the company for a clinical trial program. He turned to his daughter and said “baby, hopefully we can get you a cure now.”
What made this whole thing even worse was when he looked at my grandmother and just said “where is the baby”? That took a few days to figure out but at the time he was ill my wife was pregnant with our little girl. When we finally realized he kept asking about our baby he kept smiling upon talking about her. Our little girl was born a day earlier than her due date in November. After we were able to leave the hospital we went straight over to my grandfather’s house to show him that the baby was here.
At one point she talks about how Henrietta was not told of the effects of her procedures. Skloot writes that when Henrietta treatments were coming to an end she mentions having another child to her doctor, but the treatments had left her infertile. The doctor put in her chart that she said “If I had been told so before I would not have gone through with the treatments” (47, 48). Furthermore, skloot brings up the Lack of consent from the Lacks family discussing how no one told them that Henrietta’s cells existed until the 70’s. When Doctors and Scientists wanted to find out more about the cells Henrietta’s children were then used in research without their consent.
I chose this topic for a personal reason. One personal reason is because I was an eight-month-old baby when I was first placed in foster care. I was taken away from my biological mother when she decided to take me to the hospital. Once there the hospital staff diagnosed me with a severe bronchial infection on top of a severe skull fracture. When asked my biological mother couldn’t explain what happened and had multiple men that were not my biological father trying to give a reason for what had happened.