Aft2 Task 2

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Accreditation Audit (AFT2) Task 2
Sentinel Event
Western Governors University

Accreditation Audit (AFT2) Task 2
Sentinel Event
A1. Sentinel Event Summary
This sentinel event is directly associated with a child abduction at Nightingale Community Hospital. A 3 year old patient was having surgery at Nightingale Community Hospital on Thursday, September 14. The patient’s mother accompanied the patient before surgery and completed all consent form. An estimated time of 1 hour 45 minutes was given as the time to complete surgery and recovery. The mother informed the pre-op nurse that she would be off campus during the surgery and would return to pick up the patient in the time frame given. She also provided a phone number to
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This will improve communication throughout the process and ensure a physical identification can be matched upon discharge. * The registrar should also be granted access to the surgeon’s office notes to review any demographic information. This will ensure consistency and identification of information that may not have been documented during the surgical check-in process. * Pre-Op Nurse: The pre-op nurse is the second person in the process to interact with the patient and their family. The pre-op nurse is responsible for all pre-surgical workups for the patient. This includes medical and family related activities. The pre-op nurse communicates with the family the specific expectations for the patient’s surgery and associated timeframes. * Personnel Issues: One of the key barriers to effective interaction for the pre-op nurses is that they are not getting any information from the registrar or the surgeon related to the patients unique circumstances. There is not a communication process in place for the pre-op nurse to actively communicate with the surgeon or his office regarding a patient’s care during their day of surgery. An additional factor in this situation was the pre-op nurse documented the mother’s contact information in her notepad, but not on the

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