Sentinel Event Essay

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Sentinel event:
• A minor child was unknowingly released to the noncustodial parent (the father) after outpatient surgery.
• The custodial parent (the mother) was not aware that the noncustodial was going to pick up the patient.
• The discharge nurse discharged the minor patient without appropriate identification and/or documentation.
• The incident was considered a child abduction.
Roles of staff present during the event:
Security Responsible for responding to any patient care security issues, notification of local law enforcement.
Registrar Responsible for entering the patient’s demographics and insurance information into the electronic medical record system.
Pre op nurse Responsible for pre-operative care, nursing assessment, initiation of intravenous access, change patient into
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Utilization of this process will provide a mechanism for staff to have input into the required changes and may promote a positive working environment, tearing down the barriers faced by this department. Units that are enabled to act autonomously and define for themselves how to carry out their mission will be less receptive to changes suggested by an unknown entities (invisible policy makers) than will units in which commanders define the mission (Bazerman, 1984). The TQM model empowers employers by empowering employees.
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