Wgu Aft Task 2

2175 Words9 Pages
Root Cause Analysis A.1 Sentinel Event Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact…show more content…
There was no hand off of the cell phone number the mother provided to the pre-op nurse. As there is no documented area on any of the forms for this information, the process relies on verbal handoff and memory of the nurse. There was no alternate phone number available for the nurse to contact the mother or other designee. Recovery Nurse – The patient was transitioned from the operating room to the recovery room. As previously noted, there is no formal hand off process from one area to another within the ambulatory surgical center. The recovery nurse attempted to locate the mother in the waiting area. As noted above, there was no hand off of the mother’s cell phone number or alternate contact information. Discharge Nurse – The recovery nurse brought the patient to the discharge are post recovery. The patient’s mother had still not returned to the hospital. Again there is no formal hand off process to exchange information. The patient was reported to be anxious and crying. A call was received reporting the patient’s father was available in the waiting area. The male was brought to the area and the child was reported to appear comforted by his arrival. Discharge instructions were given and the child was released with the father. There was no reported verification of photo identification. None of the forms in the patients chart identified the father as the contact. There was no verification the male was

    More about Wgu Aft Task 2

      Open Document