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DLG AA Task 2.docx Code Pink Sentinel Event Root Cause Analysis College of Business, W

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DLG AA Task 2.docx Code Pink Sentinel Event Root Cause Analysis College of Business, Western Governors University AFT2: Accreditation Audit Code Pink Sentinel Event Root Cause Analysis Sentinel Event Summary A s ...

DLG AA Task 2.docx Code Pink Sentinel Event Root Cause Analysis College of Business, Western Governors University AFT2: Accreditation Audit Code Pink Sentinel Event Root Cause Analysis Sentinel Event Summary A sentinel event occurred at Nightingale Community Hospital (NCH) on Thursday, September 14 at 12:30 p.m. On this date, a 3-year-old female (3 y/o) arrived at NCHs Ambulatory Surgical Unit with her mother. Upon arrival, the patient was directed to the registrars desk, where the 3 y/o was registered for her procedure, a dual bilateral myringotomy (tubes in the ears). Once registration was completed, they were taken to the pre-op area for the 3 y/o to be prepped for surgery. The mother was informed that the surgery would take approximately 45 minutes to perform and then the 3 y/o would be transferred to recovery where she would spend approximately one hour. At this time, the mother informed the pre-op nurse that she had an errand to do for an older sibling. She provided the nurse with her phone number and requested a call if the surgery ended sooner than planned. However, she did state that she would return to pick up the 3 y/o when she was out of recovery. 2.5 hours later, the mother returned to the hospital. This is approximately 45 minutes after surgery and recovery time was completed. Upon her arrival, the discharge nurse revealed that the 3 y/o had already been discharged approximately 30 minutes earlier, to a man claiming to be her father. The mother became incredibly distraug. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . .

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