Hospital Sentinel Event

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NIGHTINGALE COMMUNITY

HOSPITAL.

RCA (ROOT CAUSE ANALYSIS)

FOR THE SENTINEL EVENT REPORT

HAPPENED ON MAY 14,

THURSDAY AT 9:00 AM.

1. SENTINEL EVENT DESCRIPTION.

The pre-op nurse told the mother that once Tina (The patient), a 3 years old child, went to the OR, her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour. The mother told the nurse that once Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number
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She never imagined that the father wouldn't have custody or whatever.
A few minutes later the mother came, and she was very upset and she apologized to her for the mistake that committed.

5. SECURITY OFFICER.

At 9:00AM, he got a call, telling him about a potential child abduction, immediately he responded to the ambulatory surgical unit, discharge are and interview the nurse, which it told him that a minor patient has been missing for approximately 25 minutes, he was upset that he wasn't called sooner.

6. REGISTRAR.

When the mother and the patient came to her desk, she took care of entering the information need it, in the registration section of the electronic medical record form, asked for the insurance situation and gave the mother the admission and treatment form.

She didn't ask for any other identification form, because it isn't part of the registration process, specially about any custodial information, because also it isn't part of the registration process. She just did exactly was she was tough to do and what she has been doing for a long time.

7. SURGEON.

Most likely he performed the surgery. He is the number one doctor in pediatric outpatient surgery at Nightingale Community Hospital.

8. CHIEF NURSING OFFICER.

She wasn't actually involved in the sentinel event, but she the person responsible for all the nurses at Nightingale Community Hospital. She will like to know what happened and determined a good

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