Essay on Raft Task 2

3156 Words Mar 2nd, 2013 13 Pages
RAFT Task 2
Sharon Walb
Western Governor's University






RAFT Task 2
A.1 Sentinel Event
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event).
Root Cause Analysis: Potential Child Abduction
Recently a three year old female was brought to Nightingale Hospital for an outpatient surgical procedure accompanied by her mother. They presented to the registrar who entered all information into the computer and copied insurance card, she did not obtain any parental photo identification or inquire about custody arrangements. Patient and her mother were taken to the pre-operative area to prepare for surgery and
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Staff has completed orientation to the department and organization. There is a clear void on the part of specific patient population policies that address chain of custody, and a lack of consistent training on abduction or drills.
Staffing levels were adequate and units staffed per AORN guidelines. Contingent staffing plan would be to bring in staff that are “on-call”, or offer additional hours to part-time staff, re-assign staff from other units or augment staff with help from management. All staff that float to this area have completed orientation and are aware of the current policies in place, as well as understand the job responsibilities.
Communication was lacking in a consistent manner in oral, written, electronic versions. Many pieces were available but never consolidated to present a complete picture or close the loop.
The physical environment did not play a role in this event. No documentation of an environmental risk assessment can be located. No documented deficiencies in past surveys.
Current emergency and failure mode responses in place specific to this event are the “code pink”; the drills on this response are sporadic in nature.
The culture at Nightingale permits the reporting of unsafe conditions or suggestions to improve practice in a welcoming manner, reporting is non-retaliatory.
To break down barriers to change the organization has taken the stance that all key…

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