Accreditation Audit

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RAFT –Task 2 Root Cause Analysis A-1. Sentinel Event A sentinel event is an event that happens expectantly in a healthcare facility that could result possible death, physical or mental injury to patients unrelated to natural causes of the patients illness as defined by Joint Commission (www.joint On the afternoon of Thursday, September 14, at approximately 12:30 p.m. a ‘Code Pink’ (child abduction alert) was called when a minor child/patient, Tina, was discharged to the care of her father without the knowledge of her mother with whom she was admitted with. Tina was registered into the hospital system by Katie Jessup, hospital registrar, who entered all proper demographics and all proper insurance information into the…show more content…
It is not his job to do this, however, information pertinent to the patient should be made available to the hospital. Chief Nursing Officer (CNO)—is in charge of the entire nursing staff at hospitals and hospital institutes. CNO’s are responsible for the management of nurses in their department by providing feedback, training, support, and disciplinary actions when called for. CNO’s are also accountable for the development of programs and procedures that will help the hospital institutions run efficiently and promote growth ( The role of the CNO was that of an ineffective leader in that she was unavailable (why?) when the incident occurred, however she took responsibility and accountability. Pre-op Nurse—is responsible for working closely with the attending surgeon. Her list of accountabilities include, talking with the patient or guardian forms and asking vital questions to allow for a safe operation. The pre-op nurse prepares all paperwork and makes sure all signatures have been obtained. This is done in the presence of a physician. She is responsible for taking the patients vital signs (blood pressure, temp, and heart-rate, start IV’s) to ensure that are not outside the lines of normalcy. In short the pre-op nurse will perform any duty to ensure that the patient is prepared for surgery this may include talking to family members. The nurse is also responsible

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