Root Cause Analysis Due to Sentinel Event Essay

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Analysis of Sentinel Event: Child Abduction Root Cause Analysis (RCA): Child Abduction Please note the root cause analysis and recommended action plan show evidence of the key components of the RCA matrix for the specific event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Tina, a 13 year old teenager admitted for day surgery, was inappropriately released to her father when her mother was delayed in returning to pick-up and release the daughter from the hospital. The hospital staff had no awareness of the family situation until the mother came back to the hospital and discovered that her tardiness had…show more content…
Without multidisciplinary and interdepartmental communication, it is difficult to understand the big picture—what is actually happening to the patient during the episode of hospitalization and what the impact on the organization is. Teams led by department leads can brainstorm data for better ways to communicate and recommend preventive strategies. The task force team should consist of surgeons, anesthesiologists, risk control specialists, operating room nurses, quality management staff, and research analysts. Medical staff can explain to the team how complications from miscommunication or poor labeling have an impact on the patient's health and require expensive resources such as operating room or intensive care unit (ICU) admission. A member of the risk management department might report on how much miscommunication or poor labeling costs the organization in malpractice claims and lawsuits, and someone from utilization might explain how much miscommunication or poor labeling costs the organization in excess days of stay. Someone in public relations might explore how poor publicity has had an impact on the volume of patients. Too often people in one department do not communicate with people in other departments. The medical records of patients who experienced the sentinel event should be analyzed by the team. Once the underlying causes of the event are identified through root cause analysis, the team should develop
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