Sentinel Event Case Study

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Sentinel Event
Nightingale community hospital is a quality healthcare organization which provides compassionate and cost-effective services to patients. Core values of the hospital are safety, community, teamwork and accountability. Patient’s safety comes first, but recent sentinel event involving child abduction put this value into question.
Child named Tina was admitted to NCH for care involving minor surgery. Tina was accompanied by her mother to the hospital. Register checked in the patient and collected all required information. The pre-op nurse took Tina and her mother to the surgery area and explained the surgery will take about 45 minutes, and she will be transferred to recovery areas, which will take another hour. Mother informed
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CEO promised a full investigation into this matter to find processes failure and remedy it for the future so that these kinds of event never happen. Taking proactive steps will ensure NCH will hold on to values of patient safety as stated on the mission statement.
There were several personnel involved in this sentinel event including Registrar, Pre-op nurse, O.R nurse, Surgeon, Recovery room nurse, Chief Nursing officer, Discharge nurse and Security officer. Each of these personnel has a different responsibility in the hospital.
Registrar has one of the important roles in patient care within the hospital. Their primary role is of admitting patients to the hospital along with collecting personal information and insurance information. Registrar interviews patients for all required information for hospital records and billing purpose. (St.rose Hospital, 2013) They also prepare patient chart and patient identification wristband. Accurate patient information is essential in the continuation of patient care thru out the patients
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There is a variety of tools available for conducting root cause analysis. One of the simplest and easy tool is 5 why’s. By repeatedly asking “why” can peel away symptoms and leads to the root cause of the problem (Six sigma). The “5 whys” will explore the cause and effect relationship within a problem which has to resolve. This technique is most useful when the problem involves human behavior or communication.
Root cause analysis of the sentinel event revealed different issues, but the main cause is identified as not having an official policy regarding collection of custody information, identification requirements and who is responsible to enter this information into the chart system.
Hospital staff is not aware of any official policy regarding custody information and confused about which staff’s responsibility is to enter this information.
Risk management program:
Nightingale community hospital must develop effective policy and procedure to make sure sentinel events involving child abduction never happens again. These policies need to be in place for effective training of
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