This root cause analysis summarizes a sentinel event that occurred at Nightingale Community Hospital involving the discharge of a 3-year-old patient, Tina, to her father instead of her mother who had full custody. The summary identified communication breakdowns between registration, pre-op, OR, recovery, and discharge nursing staff that failed to convey the mother's instructions and custody information. To address this, the root cause analysis recommends Nightingale implement a formal handoff procedure involving all departments to improve information sharing and ensure proper discharge of patients according to any special instructions. The effectiveness of the new procedure will be measured by analyzing communication across departments for patients requiring special discharge instructions.

1. AFT Task 2
Jessica E Thorpe
Western Governors University

2. The objective of this root cause analysis is to determine what caused and contributed to the
recent near miss that occurred at Nightingale Community Hospital. This root cause analysis will
determine specifically what happened during the event, how it was allowed to happen and why
the event happened. In order to achieve this, an investigation was done and all parties involved
were interviewed. Based on the information gathered from the interviews this is what happened
the morning of the sentential event.
Sentinel Event
On the morning of September 14, 2012 Tina the 3 year old patient involved in the event was
admitted to the hospital by her mother. The registrar followed proper procedure in the way she
was taught. The registrar did her job and entered all required information such as well as made
copies of ID’s and insurance cards. She had the mother sign all necessary paperwork that was
required and did not ask for any additional information such as custody agreements because she
was not trained to and the paperwork did not require that information. The registrar believes it is
the Nurse’s job to release patients to the right parent or guardian.
Once admitted Tina and her mother were greeted by the Pre-Op Nurse who got Tina in a gown
and performed her Pre-OP nursing assessment, administered all necessary medication and had
the mother sign all consent forms for the procedure. The Pre-Op Nursing assessment form also
did not ask for any custody information so she did not ask. Tina’s mother did however let the
Pre-Op nurse know that she would be running errands during Tina’s procedure and to call her
when Tina was in recovery. The Pre-Op Nurse took down the mother’s phone number on her
note pad that she keeps with her at all times. The Pre-Op Nurse believes it is the surgeons’
responsibility to release that information to the staff. She states that he breezes in and out of the

3. hospital after each procedure and never offers up his notes. The Pre-Op Nurse feels it is the
registrars’ responsibility to get that information and that matching wrist band should be
administered to the parent and child so that when they are discharged they can ensure the child is
leaving with the right person by making sure the wrist bands match.
The O.R Nurse says she see’s parents and children separated all the time and that imaging should
be involved with any procedure changes the hospital makes. The O.R Nurse knows departments
only look out for their own departments and see problems arise over and over again from the
lack of communication across departments. She believes each department has very little
understanding of how what one department does affect another. She believes working more
closely with security would eliminate some of the problems of children and parents being
separated.
Once Tina was prepped she went in for surgery and did an excellent job. The surgeon was
absolutely amazed that such an event took place. He says it is the nursing staffs’ responsibility
and they should step up and understand the legal ramifications of something like this happening.
He knew Tina’s mother had full custody and cannot believe the nurses didn’t know because that
information was in his notes. The surgeon says the nursing staff did not even bother to ask for
his notes which would have stated the custody information. He is the number one pediatric
surgeon for Nightingale and wants assurance that his patients are safe and that this will never
happen again.
Once the surgery was over Tina was sent to recovery. The recovery nurse watched over Tina and
once she was ready to go he paged her mother who did not respond. After a little while, when the
mother never responded, he handed Tina off to the discharge nurse. The recovery nurse did not

4. have any ideas on how to improve the current system. The recovery nurse stated that a friend
who works for another hospital says they have a formal hand off procedure but that it is time
consuming and takes attention from the patients and does not know how that would help
Nightingale.
The discharge nurse received Tina from the recovery nurse and continued to wait for Tina’s
mother. The child became agitated and very upset and the discharge nurse did not know what to
do. Tina’s father arrived and the child called him daddy and was happy to see him. This calmed
the girl and she was very happy. After waiting an additional 30 minutes for the mother the
discharge nurse explained after care procedures for Tina, had the dad sign discharge papers and
released Tina into the custody of her father. After Tina had been gone with her dad for 30
minutes the mother finally returned very upset that Tina was gone and explained she had full
custody of the child. The discharge nurse had no idea of this and knows the hospital needs to do
a better job at communicating.
Once the mother arrived and realized Tina was missing security was notified and 0900, 30
minutes after the child had been gone. A code pink for child abduction was activated and
security contacted local law enforcement. Tina was found 30 minutes later in the care of her
father. The father had taken Tina home to wait for the arrival of the mother. No charges came
about the situation but security was very upset he was not notified earlier and believes that
security should be involved in child abduction drills in all areas of the hospital and that
wristbands that are coded into the security system should be given out to keep better track of
patients.

5. The chief nursing officer was not around when the event occurred but since she is responsible for
all nurses she wants to know how and why this happened. She knows there are communication
problems amongst nurses and knows there is a need a smoother flow of information. She wants
to make changes to make sure this does not happen again.
Roles of Personnel
Registrar: Primary duties include greeting patients and families and initiating the medical
record, both written and electronic. The registrar is responsible for quality patient registrations
by obtaining thorough and accurate information in a timely and efficient manner and entering
this data correctly." The registrar collects personal data as well as payment information and
verifies health insurance coverage (Trautman).
Pre-Op Nurse: Pre-op nurses are also called pre-operation and/or surgical nurses. Pre-op nurses
mainly work within hospital settings, administering care to patients prior to surgery. Pre-op
nurses administer pre-surgery medicine if necessary, evaluate and access admission documents,
identify emergency procedures, and adhere to necessary pre-operation policies and procedures
(Cherry).
O.R Nurse: Supervises and directs patient care in an individual operating room. Ensures that
proper techniques and practices are used according to accepted standards of practice. Supervises
other personnel in the room and directs or assists as necessary. Immediately reports any unusual
occurrences to charge personnel (Kansas Heart Hospital).

6. Surgeon: Pediatric surgeons are primarily concerned with the diagnosis, preoperative, operative,
and postoperative management of surgical problems in children (Duke Children’s Hospital and
Health Center).
Recovery Nurse: After surgery, recovery nurses are patients' primary care givers. They monitor
their vital signs, clean bandages and comfort patients when they wake up from anesthesia.
Recovery nurses administer tests, analyze lab results and report back to surgeons and doctors.
They track the progress of patients' conditions, and ensure patients receive adequate rest, food,
fluids and nutrients. Recovery nurses teach patients how to clean their bandages, take medication
and care for themselves after they leave the hospital (Pratt).
Discharge Nurse: Initiates discharge planning procedures. They work with the physician and the
patient’s nurse to be certain nurse with patient that all plans are in order for the time of
discharge. They verify that the patient and the family have an understanding of these (Ward).
Chief Nursing Officer: Plans, organizes and directs hospital Nursing, Nursing Education and
other departments as assigned. Directs the personnel management activities of assigned areas;
guides subordinate directors, managers and supervisors in the selection, hiring, training and
development of staff as well as performance appraisal, documentation of deficiencies,
performance recognition and disciplinary action (Dinsmore).
Security: Main duty is to protect people, property, information, and reputation.
Responds rapidly to security emergencies within the hospital or health care setting.
Responding appropriately to routine and emergency situations in a timely manner (Forte).

7. Impeding Barriers
The first and most obvious barrier in this case is communication. The information was there all
along and because of lack of communication it was not translated to all parties involved. As in
the case with the Pre-Op Nurse she was very rushed, distracted and was on overload. She had the
information all along as to what the instructions were after Tina’s surgery but because she was
on information overload because of all of the other things going on she forgot and did not think
to past the mothers request on.
Emotions were a barrier when it came to the discharge nurse. Tina was upset and the discharge
nurse wanted to comfort her. When the father arrived Tina and the nurse were relieved. The
discharge nurse just assumed it was O.K to discharge Tina to him and did not ask or check to see
if this was O.K.
Social barriers played a role with the surgeon. He has the attitude that since he is the number one
pediatric surgeon his only responsibility is to come in, do his job and go. He believes all the
responsibility falls on the nurses and they should ask him for his notes.
For all of the others involved in the event it was a domino effect. Once the Pre-Op nurse and the
Surgeon did not relay the custody information nor the mothers’ request the others had no idea
custody was even an issue.
To improve information amongst the staff there needs to be a five minute Q&A to review any
important information about the patient when hand offs occurs. Also there should be a checklist
that has any important information regarding the patient that way if someone forgets to mention
important information during hand off they information can be found on the check list. Check list

8. can easily be filed in the patients’ folder. It should also be mandatory that at each hand off the
receiving party quickly reviews the patients chart before proceeding.
Quality Improvement Tool
The quality improvement tool that will be used to conduct the analysis is the PDSA model (Plan,
Do, Study, Act). This will allow the hospital to plan how they will observe and collect data and
what resources will be needed. The hospital can then try out the new plan, documenting
problems and beginning an analysis of the data. The hospital can then study the analysis and
reflect on what was learned. Nightingale can then modify, create or change procedures based on
analysis results and prepare for those changes.
Corrective Action Plan
To ensure this never happens again Nightingale should implement a formal hand off procedure.
The formal hand off procedure will involve all nursing staff, Surgeons, Head of Nursing,
Security, Registrar and anyone who comes in contact with patients. The head of nursing, heads
of surgery and heads of support staff and security will all be responsible for implementing,
revising and participating in the new procedure. The procedure will start off with the Registrar
asking if there are any special discharge instruction regarding the patient or any other pertinent
information. The registrar will write any additional request if any and then add the form to the
patients file at registration. The registrar will inform the receiver whether or not the patient
requires special treatment. If there are special discharge instructions the head of security will be
notified of the instructions and given the patients name and photo. The form will include a
section for each department to add comments and give feedback. At the end of the form there
will be a checklist to be filled out by the receiver asking if you received the form or did you have

9. to request it, if a five minute Q&A was performed, did the person handing off the patient inform
you of any special instructions, were you updated on the patients status and so on. This
procedure will involve verbal as well as written communication. Forms and checklist will be
required for every patient and will be written on double sided paper so one can go in the patients
file and the other in a folder to be reviewed later by a chosen department head. Each form will
include the patients’ name, the diagnosis the care plan and anything that is unusual or specific to
the patient i.e., custody arrangements. The formal hand off procedure will also require staff to
take 5 minutes or more if needed to explain what has been going on with the patient this far and
any new or pertinent information that has arisen. This will continue until the patient is at
discharge. Once the patient is being discharged the nurse responsible will take extra care in
ensuring there are not special requirements upon release and if so following those discharge
instructions exactly. Once the patient is safely discharged the head of security will be notified
once more and informed of the patients’ safe release. Once the policy is implemented training
will be given to all hospital staff on the new procedure. There will also be pamphlets and posters
around the hospital and email updates will be available if anything in the procedure changes.
Additional training will be available such as simulations and reading for all parties needing more
guidance or for whoever just wants to learn more.
To measure the effectiveness of the new procedure the extra handoff form that was stored will be
collected monthly and analyzed. Files for all patients requiring special release instructions will
be collected and analyzed for effectiveness of communication across departments and to see if
discharge took place as instructed or with problems. The hospital want a 100% rate so the
hospital is looking for 100% communication across departments especially on the section

10. involving discharge. This procedure is expected to take 60-90 days to develop and will be
available for use immediately after.
After data is collected the selected reviewer will divide the number of encounters who had
special discharge instructions’ and whose instructions were followed 100% and communication
scored 100% by the total number of encounters that required special discharge instructions and
then divide by 100 to get each communication rate across departments. Based on the findings
and percentage rate, additional revisions and changes will be made when needed.
Resources
There are many resources available in the hospital to make this procedure possible, meetings,
technology such as email, computer simulations, televisions, pamphlets, posters, seasoned
workers who have knowledge and experience in the particular area and training classes.
Nightingale will make it very possible to implement this new procedure as patient safety and
satisfaction is one of if not the most important goal.
According to the Joint Commission In 2005, a Joint Commission analysis found that 70 percent
of sentinel events were caused by communication breakdowns, half of those occurred during
handoffs (Runy 2008). The expected results of this corrective action plan is for Nightingale
Community Hospital to drastically reduce this number by implementing this procedure and
improving hand off communication amongst staff members.

11. References
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Dinsmore, D. (2007, August 2). Retrieved from
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Forte, J. (n.d.). Hospital Security Officer – Administrative and Information Managers – Health
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Pediatric Surgery (General) - Duke Children's Hospital & Health Center. (n.d.). Retrieved from
http://www.dukechildrens.org/services/pediatric_surgery_general
Pratt, J. (n.d.). Duties of a Recovery Nurse | Chron.com. Retrieved from
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Runy, L. A. (2008). Patient Handoffs. Retrieved from
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Ward, J. (2012, September 6). Patient Care: The Nurse�s Role in Discharge Planning -
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