Sentinel Event

A1. Sentinel Celebration

Review of the medical record for the specified patient (SP) was completed 09/16/12. The medical record revealed that the SP was a minor child with a diagnosis of history of repeated and persistent tonsillitis and was timetabled to have the tonsils and adenoids removed 09/14/12 at 10: 30 WAS as a great outpatient procedure. Review of the medical record for the day of 09/14/12 says the SP was admitted to the pre-admission testing region at on the lookout for: 00 WAS. At 10: 00 WAS the SP was in the pre-operative region with the peripheral intravenous collection in place and the pre-operative medications were being given. At 15: 30 ARE the SP was in the operating space (OR) and the procedure was performed because scheduled. For 11: 15 AM, the SP was moved from the OR to the post ease care product (PACU). At 12: 12-15 PM, the SP was successfully retrieved from the method and both the surgeon and the anesthesiologist removed the SP to go house. The medical record uncovered a nurse's note by pre-operative doctor on 09/14/12 at 12: 30 ARE that documented a conversation between the pre-operative nurse and the SP's mother where the mom stated she was departing to run a great errand regarding an older sibling and remaining a cell phone telephone number. The sole documented teaching from the mother was pertaining to the nurse to phone if the SP got away of medical procedures sooner than anticipated. In an interview with the PACU nurse carried out on 09/15/12 at twelve: 00 ARE, the PACU nurse explained that on 09/14/12 by approximately doze: 30 EVENING, the patient was released for home with her father, who was identified by simply his license; the PACU nurse explained that she provided written instructions to get the patient's post-operative treatment and follow-up appointment towards the father. The PACU registered nurse stated the patient's father verbalized understanding of the release instructions and left with the individual. The medical record weren't getting documentation of the encounter. The medical record also lacked documentation of any restrictions as to which in turn parent was permitted for taking the patient home. The person's mother reached the hospital on 09/14/12 for approximately 1: 00 PM HOURS to take the individual home and was really distraught the moment she discovered her daughter was not in the PACU while she predicted. There was a shift modify at one particular: 00 EVENING and the onset nurses did not know that the sufferer was released to her father. Consequently, security was called and a hospital-wide child kidnapping alert (code pink) was activated. Furthermore to hospital security, community law enforcement was also notified of the absent child. The SP's mom told a healthcare facility security officer that she plus the SP's daddy were single and she had complete custody of the SP as well as the SP's littermates. On 09/14/12 at approximately 1: 30 PM, the SP was located at the father's home, in the proper care of the father. The SP's daddy stated that he required the SP to his residence to wait for the SP's mother to arrive. No charges were submitted against the SP's father. A healthcare facility management and security personnel certain the SP's mother that this incident would be investigated and processes would be put in place to prevent it by happening in the foreseeable future.

A2. Employees

There were several employees who interactions together with the SP and her mom during the outpatient hospital method. The first person was the medical center registrar who have took the SP's demographic information in the SP's mom. The next person was the pre-operative nurse who have took obtained the SP's clinical data and health background from the SP's mother, performed the initial physical assessment (height, weight, essential signs, cardio-pulmonary, and check out toe), and obtained peripheral intravenous access. The people who have then interacted with the SP were the surgeon, the anesthesiologist, and the operating place nurses. The surgeon as well had an office visit with the SP and her mother inside the days prior to the medical procedures. The OR PERHAPS nurse took over care if the SP was...



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