Root Cause Analysis of the Sentinel Event: The Child Abduction Case

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Root Cause Analysis of the Sentinel Event Abstract This paper highlights a root cause analysis of the sentinel event in a case involving child abduction. It describes the sentinel event in addition to explaining the roles of personnel present during the event. The paper further analyses the obstacles that may slow down efficient relations among the personnel present during the sentinel event. It discusses quality improvement methods used in the root cause analysis by outlining a corrective action plan to ensure tevent does not recur. The Sentinel Event According to her nurse, Tina's surgery was expected to last for approximately 45 and she would require an additional hour for recovery before being discharged by the hospital. Tina's mother informed the operations nurse that once Tina had been taken to the operating room, she would go run an errand involving Tina's older sibling and that she would be back to pick Tina after recovering from the surgery. Tina's mother then issued the pre operation nurse with her cell phone number instructing her to call her as soon as Tina was discharged from the hospital. Tina's mother was upset to realize that she was missing and alerted the security officer. Subsequently, the hospital abduction code was activated in the hospital by the security officer. The hospital's security personnel contacted local law enforcement agencies alerting them of the presumed abduction of Tina after her surgery. The security officer realized while

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