Aft2 Task 2

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Accreditation Audit 4 June 2015 Contents A. Sentinel Event 3 A2. Personnel Involved 4 A3. Personnel Issues 6 Interactions improvement 6 A4. Quality Improvement 7 B1. Risk Management Program 8 Resources 9 Works Cited 10 A. Sentinel Event This sentinel event involves child abduction from the surgical unit of Nightingale Community Hospital on Thursday, September 14, 2014 at approximately 1230hrs. The patient, a three-year old female, arrived accompanied by her mother, for an outpatient surgical procedure at 0800hrs and proceeded to registration where all currently required documentation was completed and signed by the mother; this included the authorization forms for the surgery. After registration, the patient and her…show more content…
Specifically, the pre-op nurse who acquired the parental contact information, or upon being informed that the mother would be leaving the facility did not document it in the patient chart or pass it along to the O.R. nurse. 3) Surgeon: Was directly involved in the events leading up to the sentinel event. The surgeon was responsible for all activities taking place in the surgical suite and directly related to the surgery of the pediatric patient. The surgery was completed safely and successfully; however, the surgeon had relevant information in the patient chart at his office yet did not share this information with the hospital. He also did not supply an appropriate or accurate H&P that would have included custodial status for the pediatric patient to the hospital. The surgeon is greatly concerned in the events that lead to the sentinel event and wants to ensure that his patients will be cared for and safe at Nightingale Community Hospital. 4) O.R. Nurse: Was directly involved in the events leading up to the sentinel event. The O.R. nurse is responsible for assisting the surgeon in the surgical suite and providing continuity of care throughout the surgical procedure from pre-op to post-op. The surgery was completed safely and successfully and the patient was handed over to PACU for recovery appropriately; however, the O.R. nurse did not verify that all relevant information was obtained from

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