Sentinel Event Report The pre-op nurse told the mother.docx

Sentinel Event Report
The pre-op nurse told the mother that once Tina went to the OR,
her surgery would take about 45 minutes and
then she would go to recovery and she would be there at least
one hour. The mother told the nurse that once
Tina went to the OR, she needed to run a quick errand involving
an older sibling and would return in time to pick
her up once she got out of recovery. The mother gave the pre-op
nurse her cell phone number with instructions
to contact her if Tina got out of surgery sooner than expected.
Tina’s mother returned to pick her approximately 2 ½ hours
later and found that Tina was discharged 30 minutes
earlier.
Tina’s mother was extremely distraught, security was called,
and a “Code Pink” (hospital-wide child abduction
alert) was activated. Local law enforcement was also contacted
by hospital security. When the security officer
interviewed the mother, she shared with him that she and Tina’s
father were divorced and that she had full
custody of Tina and her siblings.
Tina was located within 30 minutes of her mother’s arrival, by
local law enforcement, in the care of her father. He
had taken her to his home to await the arrival of the mother.
No charges were filed against the father. The CEO of
Nightingale Memorial Hospital assured Tina’s mother that

this incident would be analyzed and processes put into place to
prevent this type of event from recurring.
Analysis of Key Components
RCA: Child Abduction
Please note that the root cause analysis and action plan must
show evidence of an analysis within the key
components as outlined on the root cause analysis matrix for the
specific type of 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
Briefly summarize the circumstances surrounding the
occurrence including the patient outcome (e.g., death,
loss of function).
Who participated in the analysis?
Please include a list of all team members that participated in the
analysis by position and title. Please DO
NOT include any names!

When did the event occur?
Include the date and time the event took place.
y at 12:30pm
What area/service was impacted?
Include the full variety of services impacted by the event.
What are the steps in the process, as designed? (Flow
Diagram(s))
The organization may provide a Flow Diagram(s) of the steps in
the process involving the occurrence. The
organization may also list the key steps involved in the specific
processes relating to the event. Ask--are all
issues in the flow addressed? Suggestions are outlined below.
This is how the process currently works.
Page 2 of 6
Confidential—For internal use only to support performance
improvement activities. This information is provided within the

confidentiality protections of state
statute. It is not to be distributed outside the quality assurance,
performance improvement, peer review process.
What human factors were relevant to the event?
Evaluate the role of human performance factors that may have
contributed to an error.
Parent Registers Child
Parent and Child taken to pre-op areas
by RN and prepared for surgery (pre-op
assessment done and consent signed)
Parent can accompany child to
door of OR suite
Post op, child transferred to recovery
area
Once stabilized, parent and
child reunited

Discharge teaching done and child
discharged with parents once recovered
Page 3 of 6
How could equipment performance affect the outcome?
List the various equipment utilized for that patient during the
healthcare stay. To assist in evaluating these
processes consider the following: Were bio-med checks done
and up-to-date? Was the equipment where it
was supposed to be? Why or why not? Was staff in-serviced on
equipment? How long ago? How frequently is
the equipment used? Were alarms, displays, and controls
identifiable and/or operating properly? Is the
equipment set up and performing in accordance with the
manufacturer’s recommendations? Were there
equipment recalls that were not addressed? Was equipment
designed to accomplish its intended purpose?
Were equipment parts defective? Was there a report to another
agency regarding equipment defect (FDA,
etc)?
What controllable factors directly affected the outcome?

Identify factors that may have contributed to the event that the
organization has the ability to change by
making process improvement changes.
Were there uncontrollable external factors?
Uncontrollable external factors are those factors that the
organization cannot change that contribute to a
breakdown in internal processes. An organization should not be
willing to assign many issues to this
category. Although a factor may be beyond the organization’s
control, the organization may be able to
minimize the factor’s effect on patients.
control)
What other areas or services are impacted?
List all other areas that have the potential for a similar event to
occur. This will assist in implementing risk
reduction strategies in other pertinent high-risk areas.
from pediatric patient
To what degree is staff properly qualified and currently
competent for their

responsibilities?
Include all staff present, not just those that were determined to
be involved with the event. Do not overlook
physicians and allied health practitioners/mid-levels.
Determine if staff was formally trained to perform the
specific duties or tasks involved in the event. Was the training
adequate? Was staff qualified to use the
equipment? Were competencies documented? Had procedures
and equipment been reviewed to ensure a
good match between people and tasks performed? Was there
agency staff that may not have been familiar
with procedures/equipment? Was float staff from another area
assisting with lack of orientation to the unit
they floated to? Was the individual new and performing a
function that they were not
oriented/trained/competent in performing? Was staff oriented
to the organization and department specific
policies/procedures?
Page 4 of 6
guidance to staff to directly prevent such an
incident
department/organization and did not have any

performance issues.
How did actual staffing compare with ideal levels?
Was there appropriate staffing at the time of the event to
address the required workload? Keep in mind if it
was a weekend, change of shift, holiday, break time. Document
the actual staffing in area of occurrence
versus planned staffing according to the staffing model.
Explain any variation; higher or lower staffing.
-op: Staffing model requires four RNs and one unit
secretary that is shared with post-op side.
Actual staffing was three RNs which resulted in pre-op nurses
prepping additional patients than
usual.
-op: Staffing model requires four RNs with the shared
unit secretary. Actual staffing was
three RNs.
What are the plans for dealing with contingencies? What would
reduce effective
staffing levels?
Summarize current plans in place to deal with staffing
deficiencies.
s are in place to use float pool nurses, contact part-time
staff for extra hours, or reassign staff
from other units.
How has staff performance in the relevant processes been
assessed? When was this last
performed?

Consider staff performance relative to the specific processes
associated with the event.
—No process in place at the time of incident to provide
guidance to staff to directly prevent
such an incident
How can orientation and in-service training be improved?
Was all staff oriented to the job responsibilities, organization,
and policies and procedures regarding safety,
security, hazardous materials, emergency, equipment, life-
safety, treatments, and procedures? Are policies
revised/updated, evidence based, and readily available? Have
policies or procedures changed without
providing additional training? Was a new policy developed and
staff training conducted? Do float staff or
agency staff receive training within the areas they are assigned?
Is this documented?
To what degree is all information available when needed?
Was information from various patient assessments completed,
shared, and accessed by members of the
treatment team as required by policy? Was the patient correctly
identified? Was the documentation clear
and did it provide an adequate summary of the patient’s
condition, treatment, and response to treatment?

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Was the level of automation appropriate? Identify what
information systems were utilized during patient
care.
To what degree is communication among participants adequate?
Look at this content to cover verbal and lack of verbal/written
communication(s).

And any other combination you can find during your
investigation.
To what degree was the physical environment appropriate for
the processes being
carried out?
Look closely at the environment the patient was in or was
transferred to/from. Spaces, privacy, safety, and
ease of access are a few items to consider. Was work performed
under adverse conditions (hot, humid,
improper lighting, cramped, noise, construction projects)? Had
there been environmental risk assessments
conducted? Did the work environment meet current codes,
specifications, and regulations? Was the work
environment appropriate to support the function it was being
used for?
—Physical environment did not play role in incident
What emergency and failure mode responses have been planned
and tested?
Had appropriate safety evaluations and disaster drills been
conducted? Had provisions been planned and
available to support a breakdown in operations?

de Pink” drills are done sporadically and not on routine
basis
To what degree is the culture conducive to risk identification
and reduction?
Did the overall culture of the facility encourage or welcome
change, suggestions, and warnings from staff
regarding risky situations or problematic areas? Does
management establish methods to identify areas of risk
or access employee suggestions for change? Are changes
implemented in a timely manner?
CEO, participates in meetings related to
serious adverse events.
Page 6 of 6
staff to bring opportunities and
suggestions forward that would improve patient care and the
work environment.
in patient safety rounds and
encourage open discussion of patient safety issues among staff.

What are the barriers to communication of potential risk
factors?
What is your organization doing to break down barriers to effect
change? Has the organization identified
barriers to effective communication among caregivers? If there
are no barriers, what have you done and how
do you know it has been successful? Be specific.
To what degree is the prevention of adverse outcomes
communicated as a high priority?
Explain leadership’s role and how it is put into practice,
provide examples.
established to report high-risk issues and
each of these are read and evaluated by the Patient Safety
Officer. Corrective actions are taken
on a regular basis.
Was there a literature search done?
List all sources of literature accessed to complete the analysis
and action plan. Literature may be accessed to
assist in analyzing the event to determine process breakdowns
and/or when developing actions once the root
causes have been identified to assist in developing best practice

recommendations for changing current
practice.
Sentinel Event Action Plan – OIG Guidelines
Action Plan
A detailed action plan that identifies risk reduction strategies
must be stated for each root cause identified. If a risk reduction
is not warranted for the identified
cause, an explanation is required. A risk reduction plan should
also be developed for any other issues identified as
opportunities for improvement that were
identified in the analysis but may not be considered root causes.
The following components must be addressed: risk reduction
strategy, person responsible for
implementation, date of implementation, and measures of
effectiveness. The measures of effectiveness are the same as a
performance indicator. They should
include anticipated outcome and measure whether or not the
action taken was effective.
Root Cause(s)/Opportunity for Improvement(s):
Highlight and summarize the root cause(s)/ Opportunity for
Improvement(s) Issue identified during the root cause analysis.
Risk Reduction Strategy:

Outline in detail the action plan steps taken to promote change.
Be specific. If you change a policy and procedure, summarize
the change that you are making.
Outline how you are going to implement the policy and
procedure (e.g., educate staff, perform post test for staff, etc.).
Person(s) Responsible for Implementation:
Identify by title the individual responsible for implementing the
particular risk reduction step.
Target date of implementation:
Outline the anticipated date of completion of each identified
step. Outline the actual completion date for steps already
completed.
Location of implementation:
Improvements to reduce risk should ultimately be implemented
in all areas where applicable, not just where the event occurred.
Identify where the
improvements will be implemented.
Completion date:
Date the corrective action was implemented.
Measures of Effectiveness/Performance Indicators:
Outline the plan for measuring the effectiveness of each risk
reduction strategy.

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confidentiality protections of state law.
It is not to be distributed outside the quality assurance,
Indicators must be objective, measurable, and quantifiable.
(Use outcome based measurements whenever possible)
Measures of effectiveness need to have the data collection
methodology outlined.
Using a random sample? Define random.
Give sample size and method of collecting.
Are you determining effectiveness by observation? Pre-
test/post-test? Pilot test? Audit tool? Explain.
Set a target range that reflects the desired range of performance
for each indicator
If measurement is not identified, reason must be documented.
(*)
All risk reduction measurement strategies will be evaluated and
reported to Senior Leadership within 3 months of completed and
approved RCA and updated
quarterly.
Root Cause(s)/Opportunity for
Improvement(s):

Risk Reduction Strategies Target
Implementation
Date
Responsible
Party
Location of
Implementation
Completion
Date
Measures of Effectiveness
Measure:
Measure:
Measure:
Measure:
Measure:

Measure:
Measure:
Page 3 of 3
confidentiality protections of state law.
It is not to be distributed outside the quality assurance,
Cite any books or journal articles that were considered in
developing this action plan:
Running head: ACCREDITATION AUDIT
ACCREDITATION AUDIT
Accreditation Audit Task 2
My Name

University
Course
Instructor
Date
Root Cause Analysis of Sentinel Event
Root Cause Analysis is one of the crucial element used to
improve the performance of a given institution or group of
people, mitigate harm and prevent future occurrence of adverse
scenarios without blaming an individual person for the loss
incurred. In the case study, the Sentinel examined through the
Root Cause Analysis is the medical event. The Sentinel, in this
case, involves an event in which a patient called Tina was
missing in the hospital during her surgical operation period. The
situation subjected Tina’s mother to psychological stress.
Victim’s mother was concerned with her children and raised
them alone without the assistance of her husband. Before the
occurrence not the situation, Tina’s mother was supposed to run
a quick errand that involved her elder daughter. The errand had
to terminate on time because the surgical procedure was
scheduled for exactly 45 minutes and the resting time was one
hour.
Tina’s mother gave her contacts to the pre-op nurse to contact
her in case Tina will get out of recovery before the provided
time elapses. Tina’s mother came back to the hospital after two
and a half hours. Tina had been discharged from the recovery
room some thirty minutes ago when her mother arrived. Tina
had been kidnapped from the hospital, therefore, Tina’s mother
was traumatized and decided to raise an alarm for security
assistance. The intervention of the security was effective
because Tina was found in her father’s house. The CEO of the

hospital gave an assurance to Tina’s mother that the incident
will be analyzed for justice to be done.
Roles of the personnel
The people involved during this sentinel event included;
pre-operation nurse, post-operation nurse, surgeon, and hospital
secretary. These people had different responsibilities in this
sentinel event. For instance, the pre-operation nurse was
responsible for the setting Tina ready for surgical operation.
The preparations done by the pre-operation nurse involved
carrying Tina to the operation room, reassuring Tina about the
procedure and checked for the physical signs presented by Tina.
The Surgeon was responsible for examining Tina’s background
before she proceeded to the operation providing appropriate
treatment for Tina after completion of the physical observations
and tests. The post-operation nurse was responsible for ensuring
that the condition of Tina was good after the operation
procedure, especially during the recovery time. The secretary in
the event was involved in ensuring an effective and open
communication between the patients, medical personnel and the
clients like Tina’s mother. The secretary acted as a customer
care unit and ensured that all stakeholders and clients in the
facility are served according to their expectations. The
cumulative responsibilities of this personnel were considered to
improve patient experience and customer satisfaction.
Potential Barriers that Impeded Effective Interactions for
Personnel Present
Many health facilities encounter various barriers during
their daily operations. In this sentinel, the possible barriers that
may have interfered with the effective interaction include
failure to provide directions to the medical personnel
concerning their responsibilities in the facility. Lack of
effective communication is another barrier that may have
contributed a lot to the occurrence of this sentinel event (Best,
et al., 2012). There was poor communication between the staff
who was responsible for attending to Tina and caring for the
recovered. During the secretary and the registering unit should

have questioned Tina’s mother about all relatives that may visit
the facility. A wise medical personnel will ask if the girl has
both parents or not. Tina’s mother would have mentioned about
her divorce with the husband, therefore preventing the divorced
father from accessing the recovery where Tina was. The staff
was also not communicated and directed to perform their
responsibilities. Lastly, poor communication is observed when
Tina’s mother fails to provide the actual time she will take to
come back from the errand. This delayed her from reaching the
hospital on time. The failure of the pre-operation nurse to
inform the post-operation nurse about the instructions provided
by Tina’s mother is another main contributor to this mistake.
Ideas to Improve the Interactions among the Personnel
Interaction among all staff in the facility is important for
realizing the goals of the hospital and improving patient
satisfaction. Communication is a vital component in all forms of
interactions (Krautscheid, 2008). A free communication among
all medical staff should be maintained without intimidating the
personality of the junior medical staff. The nurses should be
able to communicate with each other and with other medical
personnel in the facility, for example, the surgeon. All line of
communication should be maintained in this health facility in so
as to recognize the achievements and responsibilities of other
people and groups regardless of their position. An open
communication among the patients and health staff is always
important because it limits the occurrence of mistakes that may
arise the hospital.
Quality Improvement Tool / Root Cause Analysis
An appropriate tool that can be used to address this issue
in the sentinel is continuous improvement of all the activities in
the hospital. The management of the hospital led by the CEO
should ensure that there is a change for improvement among all
departmental groups in the facility. This technique will ensure
that patients get appropriate medication and care from the
health personnel (Prost, et al. 20130. There should be a change
in the security group in the hospital because the event would

have not occurred if they were keen on their responsibilities.
RM Program alterations to make the Sentinel Event does not
happen again
The risk management program for this hospital should address
all the weaknesses observed in the facility. The process change
should be able to eliminate challenges that may be encountered
from the application of continuous change strategy. This
ensures that the sentinel event will not happen in the future. The
process should involve training of all departmental staff and the
security personnel on effective measures on how to improve
their performance.
Available Resources
Root Cause Analysis is an effective resource that can be
used to support the risk management program because the
process involves a thorough examination of the possible
weaknesses that need to be improved (Roebuck, et al., 2011).
The application of the Root Cause Analysis will help in
achieving continuous change and progress in the hospital.
Conclusion
An open communication among all whole groups is
important because it ensures that all tasks are performed in an
orderly manner. Communication is always important because it
encourages free passage of information from one group to
another. The sentinel event would have occurred if there was
effective communication among all staff in the hospital.
References
Best, A., Greenhalgh, T., Lewis, S., Saul, J. E., Carroll, S., &
Bitz, J. (2012). Large‐system transformation in health care: a
realist review. The Milbank Quarterly, 90(3), 421-456.
Prost, A., Colbourn, T., Seward, N., Azad, K., Coomarasamy,
A., Copas, A.,& MacArthur, C. (2013). Women's groups
practicing participatory learning and action to improve maternal
and new-born health in low-resource settings: a systematic
review and meta-analysis. The Lancet, 381(9879), 1736-1746.

Krautscheid, L. C. (2008). Improving communication among
healthcare providers: Preparing student nurses for
practice. International Journal of Nursing Education
Scholarship, 5(1), 1-13.
Roebuck, M. C., Liberman, J. N., Gemmill-Toyama, M., &
Brennan, T. A. (2011). Medication adherence leads to lower
health care use and costs despite increased drug
spending. Health AffairsACCREDITATION9.

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