Essay Example on Sentinel Events: Unanticipated Events in Healthcare Settings

A1

According to the Joint Commission, a sentinel event refers to an unanticipated event within the healthcare setting, which results in a "death or serious physical or psychological injury to a patient or patients" (Carroll, 2016). Such death or injury is not related to the patient's natural course of illness. It may also be one of the many other circumstances that are defined explicitly by the Joint Commission, which may not result in the death or significant injury to the patient. Sentinel events are investigated and responded to immediately. The abduction of a patient when they are receiving treatment or other healthcare services within the hospital fits the definition of a sentinel event as espoused by the Joint Commission's definition.

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The abduction of a patient by their non-custodial parent at Nightingale Hospital as described fits the definition of a sentinel event. In the sentinel event, a patient, Tina, who happens to be a minor, is discharged earlier than the time expected by their custodial parent. The child disappeared from the hospital after a minor surgery. Tina's mother had asked to be allowed by the pre-op nurse to attend to the patient's older sibling outside the hospital as the operation and recovery proceeded. However, a lapse in the discharge policy at Nightingale Hospital allowed Tina's father to take custody of her even when he had not been the one that took her to hospital. Tina's father had divorced with her mother and was not the custodial parent as her mother had full custody. Nightingale Hospital's loose discharge policy did not have restrictions for who was allowed to discharge a minor after the end of the hospital procedure.

A2. The Roles of Personnel Present During the Sentinel Event

Registrar. The hospital registrar sits at the front desk in a hospital. The registrar leads the care process by collecting patient information. Such information includes the insurance details and patient demographic information. The registrar captures these details in the hospital system in readiness for the treatment procedures. Once the patient details get taken, they obtain signatures in the admission paperwork. Names may be required for the patient's consent to allow a medical procedure to be undertaken and to take financial responsibility for the healthcare services received. The registrar also helps to prepare a patient identification bracelet and ensures that when the patient heads to the pre-operative area, the pre-op nurse has the admission paperwork. In the interview, the registrar admitted the hospital admission and discharge procedure did not require taking the details of the custodial parent.

Pre-Op Nurse. The role of the pre-op nurse is to prepare the patient for surgery. They do this by ensuring that the patient has their gown fitted appropriately. They also ensure that the patient has their identification bracelet. The pre-op nurse starts the IV and ensures that the paperwork received from the registrar, such as consent forms, are complete. Once all the preparations are complete, the pre-op nurse performs a pre-op nurse assessment, which involves the administration of any recommended pre-op medication. If a hand-off occurs, it is the pre-op nurse that communicates with the personnel that performs the medical procedure. The pre-op nurse submitted that the hospital admission procedure did not require her to note the custodial information as it was not part of the assessment form.

OR-Nurse. The role of the OR nurse involved receiving the hand-off report from the pre-op nurse. The OR nurse prepares the patient for the procedure expected at the operating room. Part of the preparation includes assisting the anesthesiologist in monitoring the patient. During the operation, the OR nurse helps the surgeon by passing the operation instruments. When a hand-off occurs, it is the responsibility of the OR nurse to communicate with the personnel taking care of the patient. Such communication includes leading to proper and secure post-anesthesia. The OR nurse received the patient from the pre-op nurse but did not get information regarding the mother's leaving the hospital and request to be away during the period of the surgery. The OR nurse did not receive or ask for contact details for the patient's parents.

Recovery Nurse. The role of the recovery nurse begins with their receipt of the hand-off report from the OR nurse. Using the information, the recovery nurse monitors the patient as they awaken from the anesthesia. Once the patient recovers of the anesthesia, the recovery nurse monitors their vital signs and frequently assess the respiratory system for the patient. The recovery nurse provides the necessary medication in case of pain, per physician instructions. Another role of the recovery nurse is to liaise with the personnel taking over patient care once a hand-off has occurred. Such communication is needed once the patient heads to the discharge area.

Discharge Nurse. The discharge nurse receives the patient from the recovery nurse and ensures that they are in the right state before they are allowed to leave for home. It is the responsibility of the discharge nurse to ensure that the patient is in safe hands before they leave the hospital. However, in this case, the nurse claimed to have paged the patient's mother. However, the discharge nurse noted that the patient's mother did not respond or show up when the patient was ready for discharge. In the interview, the discharge nurse said that the security officer called to inform of the presence of the patient's father in the waiting area. Hence, she let the patient's father into the discharge area to interact with the patient. Once she was confident that the person was indeed the patient's father, she allowed him to leave with the patient.

Surgeon. The surgeon is responsible for any surgeries required in any healthcare institutions. In this case, the surgeon was responsible for the operation on Tina. Before any surgery occurs, the surgeon must ascertain that a consent form is duly signed. In the case of minors, custodial parents are responsible for the signing of the consent form. It is also worth noting that the surgeon or his office needed the authorization of a custodial parent to perform the surgery on Tina.

Chief Nursing Officer. The Chief Nursing Officer (CNO) is responsible for the management of all nursing personnel in her department at the hospital. The CNO's job is to ensure that the nurses at a hospital coordinate appropriately to discharge their duties. A principal responsibility attached to the CNO requires that they appoint the nurses on shift attend to patients such as Tina. It is also the role of the CNO to ensure that the nurses have sufficient resources to discharge their duties.

Security Officer. The role of the security officer is to ensure authorized access to the facility. The security officer should note the details of the person entering the hospital before allowing them entry. The security officer also provides that any person exiting the hospital signs out properly. It was the prerogative of the security personnel whom check-in patients and clients to ensure that at no single time can a minor be checked in by one guardian then checked out by a different individual without the relevant quarters gets notified of such changes.

A3. The Barriers That May Impede Effective Interaction Among the Personnel Present During the Sentinel Event

One of the significant barriers that may impede effective interaction among the personnel present during the sentinel event is poor communication. An inter-personnel team approach is needed to secure a patient and to ensure that they are safe when they leave the hospital. Proper communication reflects in the policy and guidelines that define the processes from admission to discharge. There is a need for adequate information flow so that all the levels are conversant with the patient's guardianship status. In the case of this sentinel event, there was no proper communication between the registrar and the pre-op nurse. Also, communication between the pre-op nurse and the OR nurse was insufficient. The communication lapse led to the discharge of the patient before the return of their custodial parent. The second barrier evidenced in the case is a lack of proper internal patient handling policies. There was no adequate admission, and discharge mechanism for young patients whose parents get identified and the right person handed the patient once the care is complete. Further, the personnel appeared not to understand the scope of their responsibilities. They did not consider their responsibilities to extend beyond what the hospital provided.

A3a. Ways to Improve Interactions Among the Personnel Present

The first way that Nightingale Hospital can improve interactions among the personnel present during the sentinel event is to revise the patient admission and discharge policy. The policy should require that all the details for the custodial parents get noted for young patients like Tina. Such information should flow from the registrar to the pre-op nurse, who should ensure that the OR nurse knows and delivers the information to the discharge nurse. The policy should require that a review of the patient information occurs before their discharge. The person allowed to pick the patient should be captured explicitly in the original forms signed when the patient gets admitted.

The second way to improve the interactions is to introduce technology. The hospital may invest in a technology that takes the biometrics of the person allowed to take the patient after discharge.

A4. Quality Improvement Tool to Be Used to Conduct the Root Cause Analysis

The essential tool for quality improvement after this sentinel event is brainstorming. Brainstorming is a tool that improves cooperation and collaboration among the personnel to work collectively towards a solution. The first component of brainstorming would be for the hospital to convene a meeting. Once everyone gets notified of the meeting, the agenda of the meeting should flow to all the personnel. During the session, each staff should get an equal opportunity to engage and share their perspectives. The collective approach should help to identify the root cause by the end of the meeting. Also, the personnel should work in collaboration to set up strategies to prevent the reoccurrence of the sentinel event. Each of the staff should understand their duties and responsibilities. Further, the personnel must acknowledge the roles and responsibilities of their colleagues and note that their responsibilities intersect.

B. A Corrective Action Plan

B1. Risk Management Program or Process Change to Ensure That the Sentinel Event Does Not Recur

The right risk management process that fits this sentinel event would involve five stages (Johnson, 2016). The initial step would involve setting up a root cause analysis team. The multidisciplinary team would consist of personnel drawn from all the vital departments. The second stage of the process would involve collecting information that is useful for the problem definition. The third stage would be to collate and organize the data to determine patterns occurring during the event and if similar trends are evident in other scenarios. In the fourth phase, the factors contributing to the sentinel event get captured. The last stage involves using the information obtained to draw an action plan.

B1a. Resources Available to Support These Changes

The Joint Commission offers an outline for addressing sentinel events (Reak et al., 2016). The guideline is a universal resource that proposes tested strategies that help to mitigate risks and help to realize improved hospi...