Accreditation Audit Essay

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Nightingale Community Hospital Root Cause Analysis (RCA) for the Sentinel Event Report that happened on September 14 at 0900. 1) SENTINEL EVENT Tina, a 3 year old minor was admitted to the hospital OR for a bilateral myringotomy, an outpatient surgery, which was expected to last approximately 45 minutes. Following surgery, Tina would be transferred to recovery to be monitored for approximately 1 hour. Tina’s mother informed the pre-op nurse that she needed to run an errand involving Tina’s older sibling and she would leave as soon as Tina was taken into surgery. The mother stated she would return in time to pick Tina up as soon as she was released from recovery. She provided her cell phone number and asked to be contacted if Tina’s surgery was completed earlier than expected. 2 ½ hours later, Tina’s mother returned to pick her up and was extremely distraught to discover that her child had been discharged 30 minutes earlier. Hospital security was notified at 0900 and a “Code Pink” (hospital-wide child abduction alert) was initiated. Security notified the local police department to report the incident. The hospital security officer noted Tina’s parents were divorced and the mother had legal custody of her children. Local law enforcement located Tina approximately 25 minutes after her mother’s arrival to the hospital, in the care of her father. Tina was very happy when she saw her father. After waiting an additional 30 minutes, he offered to take Tina home to wait for her mother’s arrival. No charges were filed against the child’s father. The CEO of the hospital pledged to analyze the incident and ensured Tina’s mother processes would be put into place to prevent this type of event from recurring. (Accreditation Audit Case Study - Task 2 Artifacts, 2012) 2) PERSONNEL Nightingale’s personnel played the following roles during the sentinel

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