Aft2 Task 3

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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. The nurse told her the procedure would take approximately an hour and forty five minutes, which included recovery. The mother handed the nurse her cell phone number and asked to be called if the surgery was shorter than predicted. The mother insisted that she was only gone for two and a half hours, and when she returned to pick up her child, the child had been discharged to the father thirty minutes prior. She became very agitated, and security was called for assistance. She informed the security officer that she and the father of the child were divorced and that she retained full custody. The security officer engaged the hospital alert system for abducted children, as well as contacted the police authorities. Approximately thirty minutes later, the police found the daughter to be with her father waiting for the mother to pick her up. Root Cause Analysis – To actuate the root cause of the sentinel event, as well as investigation of information obtained from the Nightingale Hospital reports. These are then compared to frequent root causes from the 2004-2012 Joint
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