Description of the Sentinel Event
Tina was taken to a medical institution for a surgical procedure by her mother. The procedure was supposed to last for approximately forty-five minutes and a recovery process was supposed to follow immediately after the procedure. The mother of the patient had a quick errand to ran that was involving her older sibling. As a result, she informed the nurse about the circumstance so that she could be informed once Tina was discharged from the hospital. Tina's mother gave the nurse her telephone number and provided instructions on how to contact her in case the surgery was finished before schedule. The mother of the patient came back only to find out that her daughter had been discharged earlier than expected.
Due to the concern that she had for her daughter's safety, Tina's mother became distressed and caused havoc in the hospital to the extent that security had to be involved. This havoc resulted to a "Code Pink" being activated since it was highly extreme. Police from the local area were also involved in the case since Tina's mother was unaware of her location. After a detailed interview, she informed the security officer that she was no longer married to Tina's father since they had divorced. After the divorce, Tina's mother became responsible for her daughter and her husband was not granted any permission to stay with her. Later on, Tina was found with her father and he informed the security officer that he had taken his daughter to his house so that she could wait for her father. Tina's father was not filed with any charges concerning the whole situation. The management of the medical institution informed Tina's mother that her case was being reviewed to avoid its reoccurrence in the future.
Roles of the Personnel Present
The Security Officer- responsible for guaranteeing the safety of all patients in the hospital. He is supposed to ensure that risks such as theft and robbery do not occur in a hospital. In this sentinel event, the security officer is supposed to prevent the occurrence of child abduction.
Hospital Registrar- responsible for recording the details of all patients treated in the Nightingale Community Hospital. Such information includes their names, ages and medical condition.
Surgeon- responsible for carrying out the surgery on the patient.
Discharge Nurse- clears patients who have been permitted by the physician to leave the hospital. This member of staff also provides further instructions on the medication to take after the surgery.
Pre-op Nurse- prepare a patient for the surgical process by dressing him or her accordingly and cleaning the patient when necessary.
Barriers that May Impede Effective Interaction
Proper communication is crucial in any health organization (Roter and Hall, 2006). It allows physicians and nurses to interact effectively with patients and their guardians (Roter and Hall, 2006). In this sentinel event, the primary barrier that may impede effective interaction is the appropriate communication between the discharge nurse and Tina's mother. Proper communication is also missing from all departments of the medical institutions since this is the reason why Tina's mother was not contacted about the discharge of her daughter. Nightingale Community Hospital should come up with a system that allows all departments to contact one another especially when a medical situation connects such departments. This can avoid confusion from occurring within the hospital in the future.
All personnel in the medical institution should also be provided with tasks that they can handle comfortably. Such staff should not be overworked since they can forget easily about crucial details that can result in more incidents in the future. The margin of error can be significantly minimized by giving each worker few tasks. This is because the level of concentration would be improved by reducing the tasks provided to each person. The staff employed at this medical institution should also be increased to ensure that there is no shortage of employees at the hospital. Increasing the number of staff would result in an effective operation within the medical institution.
Quality Improvement Tool to Conduct Root Cause Analysis
A tool that records the appropriate information concerning patients admitted to the hospital can be used to prevent future occurrence of a similar incident (Battles et al., 1998). This tool can be used to record the custodial information of the patients especially if they are young to avoid confusion when it comes to their discharge (Battles et al., 1998). Ellwood and Jencks (2004) suggest that in America, the number of single parents is high. This means that all medical institutions should be aware of the custodial information of their patients to prevent cases of child abduction. In this sentinel event, the medical institution involved contains an electronic form that can be used to correct the required details concerning admitted patients. This resource can be used to avoid the same incident from reoccurring in the future.
If the electronic form used in Nightingale Community Hospital does not contain a space for custodial information, changes can be introduced in the form to provide a space for such information since its very important. All nurses in the hospital should be informed about the changes in the electronic form to ensure that they are aware of the new features of the form. Physicians who are responsible for performing surgeries should also be notified concerning the changes in case they are required to fill any details concerning the custodial information of their patients. Once nurses become aware of all details concerning patients and their custodians, it becomes difficult for child abduction cases to be experienced in a medical institution.
Risk Management Program
As stated earlier, the electronic form of the medical institution can be changed to provide space for the addition of custodial information. This change can prevent cases of family abduction in medical institutions. A program that enhances communication between departments should be introduced to ensure that all personnel in a health institution are aware of the occurrences in it. The government of a nation can also be involved in such a program to enhance the services provided to all patients. Funds provided by the local or state government can be used to make changes to the departments of a medical institution to guarantee smooth communication flow. Improving the level of communication means that confusion concerning custodial information can never occur in a medical institution.
The risk management program recommended in this case can focus on family abduction cases. This program can be used to allow the medical institution to obtain all details concerning the admitted children. Such information can be based on the state of marriage of their parents and any other family member that is involved in their protection. Correcting such details can allow a medical firm to guarantee the safety of its patients since, after treatment, they can be provided to the appropriate parent or guardian. This means that cases of custodial interference can be minimized, and it can become simple for all personnel working in the hospital to discharge patients. Some divorced parents who denied the liberty of being custodians of their kids by the court tend to take advantage of their admission in hospitals. Due to the confusion that may arise, such parents are offered the protection of such kids after discharge since most nurses are unaware of the situation. These incidents can be prevented by the risk management program recommended in this case.
One of the resources available to support the changes recommended in this case includes the staff of the medical institution. These workers can be informed concerning the new changes to ensure that they implement them in the future to prevent cases of child abduction. The community surrounding the hospital can also be informed concerning the new changes to ensure that they offer their support to implement the changes. Such support can be in the form of understanding and comply to the changes once they take their children for admission in the hospital. The resources of the hospital can be used to offer it a competitive advantage. Minimizing cases of family abduction can improve the public image of the hospital. The local government can also be used as a resource to improve the changes recommended in this case. The proper combination of these resources can result in an overall improvement of the services provided by the hospital.
Battles, J. B., Kaplan, H. S., Van der Schaaf, T. W., & Shea, C. E. (1998). The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. Archives of pathology & laboratory medicine, 122(3), 231.
Ellwood, D., & Jencks, C. (2004). The spread of single-parent families in the United States since 1960.Roter, D., & Hall, J. A. (2006). Doctors talking with patients/patients talking with doctors: improving communication in medical visits (Vol. 2). Westport, CT: Praeger.
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